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ALD Connect - The Myelin Project Patient and Family Support Program
Financial Assistance Application
For questions or comments regarding the application process, please contact us at
info@aldconnect.org
. Please note that the applicant must fill this out with their own information.
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* Indicates required question
Email
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Your email
First Name
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Your answer
Last Name
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Your answer
Full Address (including city, state, zip code)
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Your answer
Phone Number (with area code)
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Your answer
Patient First Name
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Your answer
Patient Last Name
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Your answer
Patient's Diagnosis (ALD, AMN)
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Your answer
Patient's Physician (BMT, Endocrinologist, Neurologist)
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Your answer
Total Annual Household Income
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Your answer
How many adults and children live in your home?
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Your answer
Please tell us about your situation.
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Your answer
What specifically would the funds be used for? Please be as detailed as possible. This increases the chance your application being funded. The committee will deny requests that are unclear and not specific. ALD Connect does not send cash, and it is very difficult for us to send international payments. Please keep this in mind.
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Your answer
Are you willing to provide personal identifiers such as your social security number and/or login credentials to online bill pay portals to ALD Connect for purposes of making a payment on your behalf?
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Yes
No
Have you or a family member previously submitted a grant application for this program? At this time, we are only considering applicants who have not previously received assistance from ALD Connect.
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Yes
No
Have you requested financial assistance from any other organizations? If so, which ones?
Your answer
Have you had a change in circumstance that requires urgent financial assistance? If so, please explain. If not, enter "N/A".
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Your answer
ALD Connect requests that all awardees provide us with feedback that can be used online or in printed materials to help us convey the importance of the program to donors. Do you agree to provide feedback and allow us to use it as we see fit?
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Yes
No
Please send documentation of your total household annual income, patient's diagnosis, and documentation of what you need paid or reimbursed (bill or travel expense) to
info@aldconnect.org
. Have you completed this step?
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Yes
No
How did you hear about us?
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Your answer
Please verify your information.
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I certify that the above information is true and correct to the best of my knowledge.
Required
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