Financial Assistance Please enable JavaScript in your browser to complete this form.Eligibility - Step 1 of 8Eligibility Applying for Financial Assistance through Helping AMC Families Incorporated Who can apply? Individuals who have been diagnosed with Arthrogryposis or the parent/guardian of an individual diagnosed with Arthrogryposis.How often can I receive assistance? Applicants awarded financial assistance will receive $5000 (USD) per year which can be used towards requested assistance and needs approved by Helping AMC Families Incorporated. The award does not have to be spent on a single request and the use of any remaining balance can be requested by submitting subsequent applications for up to one year from the month of the first award. Most awards will be paid directly to the supplier(s), rather than via reimbursement or distributed funds. Any awards granted through reimbursement will require submission of itemized receipts. Any remaining balance left in the anniversary month of the award will be returned to the general pool of funds, to be re-distributed to other AMC families as needed.What types of assistance are available?Helping AMC Families Incorporated will assist with expenses directly related to the care and maintenance of the individual affected by Arthrogryposis. If you have a need that is not already listed here, please feel free to apply and describe your request as this is not an exhaustive list of items we are able to help with. Medical expenses related to thecare/treatment of Arthrogryposis Insurance premiumsCopaysCoinsurancesOut-of-pocket expensesMedical equipmentAdaptive clothingOrthoticsOrthotic accessoriesMedical suppliesMedical equipment Medical travel expenses related to consults/appointments/surgeriesAirline ticketsMileageGround transportationParking expensesLodging expensesMealsGroceriesTolls Other expenses related to accomodations/quality of life Home improvementsVehicle adaptationsVehicle accessibility How long does it take to receive a determination?We understand that needs can be critical and that the outcome of this application can have an impact on scheduling and planning for important medical care. For that reason, if you require assistance of a more immediate nature we highly recommend seeking out financial assistance that is geared towards emergency funding. While we will do our very best to process all applications as they come in and as quickly as possible, we cannot guarantee a response to an application within a certain length of time. Additionally, applications may be held for a period of time for various reasons and may be approved for months in the future (with the applicant story and funding earmarked months ahead of time) and this requires careful planning on our end to ensure each approved applicant receives the same quality level of attention and care by our organization. We will do our very best to keep you updated!What is expected of me?A complete picture of what you are asking for by filling out the application in full and truthfully, including all details, supporting documentation, and information necessary for us to make a decision. Once approved we will need to obtain from you a written bio and information about your journey with AMC and your needs, as well as photos/videos/supporting materials to build a story page for you on the helpingamcfamiles.org website. After approval and posting of your story, we require follow up communication to report any changes or additional approvals from other organizations, a follow up story once the request has been completed, and any receipts or additional supporting materials required to document your award. AUTHORIZATION TO RELEASE INFORMATIONBy signing below, I hereby authorize the use or disclosure of any provided health or personal information to any board member, employee, contractor, or other professional retained by, or working with, Helping AMC Families Incorporated (the “HAMCF”). I certify that I am either (a) an applicant seeking assistance from Helping AMC Families Incorporated or (b) have the legal power and authority to release such health and personal information on behalf of the applicant. Further, I certify that I am mentally competent to make medical and/or financial decisions for the applicant. I understand that the information in the applicant’s/my health record may include information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. I understand that I/the applicant have the right to revoke this authorization at any time. I understand that if I/the applicant revoke this authorization I/the applicant must do so in writing and recover and destroy all copies of this document that I/the applicant have previously distributed. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand that authorizing the disclosure of this health, financial, or other related information is voluntary. I can refuse to agree to this authorization. I understand I/the applicant may inspect or copy the information to be used or disclosed, as provided in CFR 164.524.I understand that HAMCF has sole discretion in determining whether to grant me any assistance and that, by submitting this application or seeking assistance from HAMCF, HAMCF does not in any way guarantee, agree, contract, or promise to me that I will be offered or receive any assistance of any kind from HAMCF.I grant Helping AMC Families Incorporated the right, in their sole discretion, to use, copy, reproduce, publish, distribute, publicly display, or otherwise make sure of my name, image, and likeness, in any and all media now known or hereafter devised, including but not limited to print, online, digital, video, social media, and in connection with all websites or services offered by Helping AMC Families Incorporated, from this date and continuing forever, without any compensation to me. I waive any and all claims, actions, causes of action, suits, or damaged related to rights of privacy, rights of publicity, copyright, trademark, or other personal, intellectual property, or moral rights arising out of or in connection with the use of my name, image, or likeness by Helping AMC Families Incorporated. I release, indemnify, and forever hold harmless Helping AMC Families Incorporated and their respective officers, directors, agents, members, representatives, employees, and volunteers from and against any claims, liabilities, judgements, damages, actions or cause of action, including but not limited to, personal injury, death, or damage to or loss of properly, relating to or arising out of my submission of my application, decisions made of discretion exercised by the charity, including but not limited to, the offering or not offering to me of the assistance requested by my application or any other assistance, and the manner in and means by which any assistance to which I am offered or granted is administered by the Helping AMC Families Incorporated.Lastly, I hereby permit Helping AMC Families Incorporated to use and retain the health, financial, personal, or other related information provided to Helping AMC Families Incorporated in Helping AMC Families Incorporated sole and absolute discretion. I give Helping AMC Families Incorporated authorization to speak with any other AMC/medical travel assistance programs. Signature *Clear SignatureNextWho is the AMCer you are applying for today?Myself, an adult AMCerI am the parent/legal guardian of an AMCerNextAdult AMCerName of Adult AMCer *FirstLastEmail of Adult AMCer *Phone of Adult AMCer *Address of Adult AMCer *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryBirthdate of Adult AMCer *Parent/Guardian of AMCerName *FirstLastEmail *Phone *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryRelationship to AMCer *Name of AMCer *AMCer's Birthdate *PreviousNextMedical InformationArthrogryposis Type: *Proof of Arthrogryposis diagnosis * Click or drag files to this area to upload. You can upload up to 3 files. e.g., medical documentation, letter from a medical provider, etc. Please describe your request in detail *Proof of need(s) * Click or drag files to this area to upload. You can upload up to 10 files. Please provide documentation or other proofs that support your request. This could include appointment confirmation, surgical treatment plans (with dates), prescriptions for equipment or other medical needs, photos of inaccessible home space, etc. We do not accept mobile screenshots as proof.PreviousNextFinancial InformationPlease describe your financial need/situation in detail *What sources of income do you currently have? *What other organizations have you applied to for help with this request? *Which of those organizations have approved assistance requests? *Are you currently running any fundraising campaigns? *YesNoPlease provide us with the campaign information (include any links if available, a page description, and amount raised)PreviousNextEstimated ExpensesSelect expenses that you would like Helping AMC Families to assist with *Airline expensesGround transportation expensesLodging expensesMileage expensesParking expensesFood expensesMedical insurance premiumsCo-insurance/out of pocketPhysical/Occupational therapy sessionsEquipment expensesOrthotics expensesHome improvement expensesOtherList your airline expenses *Preferred airline, itinerary information, list of passengers, necessary accommodations, and estimated costsSupporting files - airline expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your ground transportation expenses *Mode of transportation, company, location, estimated number of trips, estimated cost per trip, purpose of travel Supporting files - ground transportation expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your lodging expenses *Name of location with city and state, dates of stay, lodging rateSupporting files - lodging expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your mileage expenses *Start and end location for all trip segments (e.g., home address to hotel, hotel to doctor's office, etc.)Supporting files - mileage expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your parking expenses *Location, individual dates, chargesSupporting files - parking expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your food expenses *Length of trip, location, number of travellersSupporting files - food expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your medical insurance premiums *Insurance company, State, policy holder, cost per month for AMCer onlySupporting files - medical insurance premiums * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your co-insurance/out of pocket expenses *Provider(s), date(s) of service, service(s) provided, itemized chargesSupporting files - co-insurance/out of pocket expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your Physical/Occupational therapy sessions expenses *Provider, location, date(s), out of pocket costsSupporting files - Physical/Occupational therapy sessions expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your equipment expenses *List of items required, vendor name(s), cost of item(s)Supporting files - equipment expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your orthotics expenses *Date of last orthotics set, company name, type of orthotics/updates necessary, description of orthotics, costSupporting files - orthotics expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your home improvement expenses *Need for accommodations, description of home improvement(s), itemized list of purchases required with individual costs, cost of installation (contractor, permits, etc.)Supporting files - home improvement expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.List your required other expenses *Itemized list and cost for any medicines, health and wellness products, tapes/wraps, hospital stay needs, shoes, socks, etc. Supporting files - other expenses * Click or drag files to this area to upload. You can upload up to 20 files. Please upload documents, photos, receipts, bills, or other supporting files to accompany your request. We do not accept mobile screenshots as proof.PreviousNextConfirmationI have uploaded all necessary supporting documentation required in order to be considered to receive funding *YesIf you forgot to include necessary supporting documentation please upload below Click or drag a file to this area to upload. I understand that Helping AMC Families will cross-reference my request with other funding organizations *Yes, I understandI understand that should my funding application be approved, Helping AMC Families will share our experience with AMC and our fundraising story on their website and social media. I agree to provide photos, information requested, and a written description of our story for this purpose.Yes, I understandMy signature below certifies that the information I have provided is accurate and current upon submission of this application *Clear SignaturePreviousNextSubmit your application belowThank you for taking the time to submit your application to Helping AMC Families. We understand how important this funding can be! Our hope is to evaluate each application thoroughly and respond within 6 weeks. If you have any questions or wish to provide additional information/documentation, we can be reached at Applications@HelpingAMCFamilies.orgSUBMIT APPLICATION Share this:TwitterFacebookLike this:Like Loading...