Who We Help

Apply Now for prosthetic funding to fulfill your ambitions.

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Who we Help

Help amputees whose goals, passions, and active lifestyles require prosthetic technology beyond what standard insurance coverage provides. Includes athletes, active lifestyles, and personal passions.

Applicant Information

Funding Request

Prosthetic Quote

Prosthetist Verification

Financial Verification

Photos

Full Name*

Address *

Email Address *

Phone Number *

Amputation Level and Cause*

Veteran Status *

What prosthetic device/component are you requesting assistance for? *

Total cost of device *

Insurance contribution*

Applicant contribution

Amount requested from nonprofit

Personal Statement *

Prosthetic Quote

Upload an itemized estimate from a licensed prosthetist showing: Device requested , Total cost , Insurance coverage , Remaining patient responsibility* No file chosen

Prosthetist name*

Prosthetist Clinic*

Prosthetist Email*

Prosthetist Phone Number*

Upload one: W-2 , 1040 Tax Return , SSI/SSDI Documentation * No file chosen

Applicant annual income*

Household income*

Number of dependents*

Employment status*

NameActivity/sport photo* No file chosen

Applicant certifies all information is accurate and understands funding is not guaranteed.