Date of Birth * Guardian Name if the person in need is a minor Guardian Date of Birth Guardian Spouse Date of Birth 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 * 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 Do you have Insurance? * If yes, Branch of Service If Yes, please list Insurance Information Date Enlisted Insurance Card Front & Back Rank
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.
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.
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.