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)

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

*If your application is approved, we will require a prescription authorizing treatment for a prosthetic.
* Please note our approved clinics may require additional medical history from you or your health care provider.

Military

Insurance Information

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.

APPLICANT / GUARDIAN EMPLOYMENT INFORMATION

* 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.
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 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.
Max file size: 20MB
Max file size: 20MB
Max file size: 20MB

Fundraising Opportunities

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):
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.

Disclaimer: 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.

50 Legs in 50 Days, Inc. is a tax-exempt charity under the IRS code section 501(c)(3), Tax ID# 45-3446373

Copyright © 2019 50 Legs All Rights Reserved

P.O. Box 1086
Lithia, FL 33547

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