Scoliosis Bracing

1. Applicant Name (required)

2. Email Address (required)

3. Address (required)

4. City (required)

5. State (required)

6. Country (required)

7. Zip Code (required)

8. Phone Number (required)

9. Are you a single parent? —Please choose an option—YesNo

10. Are you a United States Resident? —Please choose an option—YesNo

11. Are you a resident of California, Florida, Texas or Wisconsin? —Please choose an option—YesNo

12. Patient Name (required)

13. Age of Patient (required) —Please choose an option—0 - 3 years old4 - 11 years old12 - 18 years oldover 18

14. Patient Curve magnitude (required) —Please choose an option—34º or Lower35º - 49°50º or Greater

15. Do you have other children with current brace treatment? —Please choose an option—YesNo

16. If so, how many?

17. Are you or a family member coping with any other health issues? If so, please explain:

18. Do you currently volunteer, or do you have an immediate family member who does? If so, who and how many hours have you completed in the last 12 months?

19. Average Household Income (required)

20. How did you find out about Align Scoliosis Foundation? (required)

21. It is recommended that you wear your BRACE as was prescribed by your MD. Will you: —Please choose an option—Agree to do this every dayWear the brace half those hoursWear the brace the time prescribed a few times a weekProbably won't wear it

22. Who is the prescribing Medical Doctor? (required)

23. Who is the orthotist providing the BRACE? (required)

24. What is the type of BRACE you are applying for this funding?

25. What is the company name where your orthotist works? (required)

26. What type of Insurance do you currently have? (required)

27. How much is the insurance company going to pay for the BRACE you are applying for? (required)

28. If the insurance company pays you or the company who is providing the BRACE, more than listed above, we ask that you inform ASF about this amount paid, once the insurance company processes the final claim. Do you agree to inform us? (required)

29. What is your yearly deductible?, Has it been met? (required)

30. Are you willing to provide a ASF patient testimonial after you start treatment? —Please choose an option—YesNo

31. Have you previously received ASF funding? —Please choose an option—YesNo

32. If so, did you provide a testimonial? —Please choose an option—YesNo

Hardship Letter (required)

Please describe your hardship, by outlining your main points from the letter, using one sentence per point (maximum of 5 bullet points and or 5 sentences).

Personal Letter of Recommendation (A letter from a friend or family member explaining why you are a good candidate)