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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Email *
First Name *
Last Name *
Full Address (including city, state, zip code) *
Phone Number (with area code) *
Patient First Name *
Patient Last Name *
Patient's Diagnosis (ALD, AMN) *
Patient's Physician (BMT, Endocrinologist, Neurologist) *
Total Annual Household Income *
How many adults and children live in your home? *
Please tell us about your situation. *
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. *
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? *
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. *
Have you requested financial assistance from any other organizations? If so, which ones?
Have you had a change in circumstance that requires urgent financial assistance? If so, please explain. If not, enter "N/A". *
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? *
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? *
How did you hear about us? *
Please verify your information. *
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