Application for Assistance

IMPORTANT NOTICE
50 Legs has an exclusive partnerships with the following providers.
We encourage you to visit their websites and become familiar before applying for assistance.

Prosthetic and Orthotic Associates
(Orlando, FL)

Prosthetic and Orthotic Associates
(Metairie, LA)

Prosthetic and Orthotic Associates
(Chattanooga, TN)

Name of Person in Need *

First

Last

Date of Birth *

Guardian Name if the person in need is a minor

First

Last

Guardian Date of Birth

Guardian Spouse Name

First

Last

Guardian Spouse Date of Birth

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Own or Rent *

Own
Rent

How Long *

Less than 1 month
1-6 months
1-3 years
Never

Monthly Mortgage or Rent Payment *

Email *

Phone *

Have you been convicted of a misdemeanor and/or a felony? If yes, please describe your conviction *

Have you been adjudicated of a crime? If yes, please describe *

If you answered yes to any of the questions regarding criminal history, please list city and state where crimes occurred *

Applicants must be a US citizen or a permanent resident of the US. Include a readable copy of your photo ID. If not a US citizen, you must send a copy of your Permanent Resident Card.

Medical Information

Height *

Weight (Current and Average since amputation) *

Side of Amputation *

Amputation Level *

Above Knee
Below Knee

Shoe Size *

Month & Year of Amputation *

Have you been outfitted with a prosthetic since your amputation? If so, when were you last fitted? *

Do you have pain in your residual limb while not wearing a prosthesis? If yes, please explain. *

What type of prosthesis are you requesting? *

*If your application is approved, we will require a prescription authorizing treatment for a prosthetic.

Please list any pre-existing medical conditions

* Please note our approved clinics may require additional medical history from you or your health care provider.

Military

Insurance Information

Are you a Veteran? *

Do you have Insurance? *

If Yes, were you honorably discharged

If Yes, please list Insurance Information

If yes, Branch of Service

Insurance Card Front & Back

Date Enlisted

Please provide a readable copy of your current insurance card, front and back. 50 Legs will use any insurance benefits available to assist in the cost of the prosthesis. *If a copy of your insurance card is not attached it may delay your application process.

Rank

Date of Discharge

APPLICANT / GUARDIAN EMPLOYMENT INFORMATION

Applicant or Guardian Employer *

Position *

Spouse Employer

Spouse Position

Combined Annual Income *

Assets / Please list all assets below *

* 50 Legs has exclusive partnerships with Prosthetic and Orthotic Associates in Orlando, Florida (poacfl.com), Prosthetic and Orthotic Associates of Louisiana (poanola.com) and FDR Center for Prosthetics and Orthotics in Nashua, NH and Burlington, MA (fdrcenter.com). We encourage you to visit their websites before applying for assistance with 50legs.

Are you (the applicant) able to provide your own transportation to the facility nearest to you? *

Are you (the applicant) able to provide your own hotel accommodations if necessary? *

Note: All applicants (and guardians, if applicable) are responsible for their own vehicle and food costs while being assisted.

Your Story (Bio)

Upload Photos (Minimum 1)

Please tell us your story (Bio), including a description of the events that occurred causing you to become an amputee: *

Please upload a picture of yourself, as well as a picture of your current prosthetic or limb. This will help us to better identify the type of prosthetic you are requesting.

File Upload *

Max file size: 20MB

File Upload

Max file size: 20MB

File Upload

Max file size: 20MB

Fundraising Opportunities

Will you be willing to volunteer in fundraising activities or host a fundraiser for 50 Legs? *

How did you hear about 50 Legs?

Consent & Authorization

I hereby irrevocably consent to the participation in interviews, the use of quotes, and the use and or taking of photographs, movies or audio or video tapes of the applicant named above. I also irrevocably grant to 50 LEGS the right to edit, use, and reuse said products for all purposes including use in print, on the internet, and in all other forms of media by 50 LEGS and or their assigns. In agreeing to this Consent and Authorization, I hereby give 50 Legs permission to conduct a criminal background check. Signature of Applicant (if 18 or over):

I (we Agree to) Consent and Authorization *

Signature / Type your name here to apply consent *

FLORIDA REGISTRATION# CH39076 A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE (800-435-7352) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE

Please keep in mind that, due to the sheer volume of requests we receive, we are unable to provide assistance to all individuals who apply.

Name