Medical Equipment & Therapy Application

This application is for families of children with disabilities who are looking for financial assistance to access durable medical equipment and/or physical, occupational, speech, aqua or hippotherapy services for their child. To receive assistance through these programs, you must demonstrate a level of financial need as well as present a prescription from a medical professional. Each case is reviewed on an individual basis.

If you have already received Variety’s assistance in the past for equipment or therapy, please contact equipment@varietystl.org or therapy@varietystl.org for separate instructions instead of completing this application.

Child’s Information

Child's Name(Required)

First Last

Birth Date(Required)

MM slash DD slash YYYY

Gender(Required)

Social Security No.(Required)

Child’s Primary Diagnosis(Required)

Additional Diagnoses

After receiving your application, Variety may request proof of diagnosis.

Parent/Guardian’s Information

Primary Guardian(s)(Required)

Relationship to child(Required)

Parent/Guardian's Birthdate(Required)

MM slash DD slash YYYY

Primary Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

County(Required)

Phone(Required)

Email(Required)

*Your response to the following question is optional and will not affect the status of your application. The information requested is useful to St. Louis Variety in grant applications and other activities seeking additional funding for our assistance programs.

What is your child’s race/ethnicity

DMH Waiver

Variety is required to provide its funding partners with the status of program participants who receive funding through the Department of Mental Health waivers.

Does the child have a Missouri Department of Mental Health (DMH Regional Office) file?(Required)

Yes

What is their DMH ID number?

Please select if the Variety participant has any of these DMH Medicaid Waivers.(Required)

Community Support Waiver

Partnership for Hope Waiver

MOCDD (Sarah Lopez) Waiver

Comprehensive Waiver

No, the participant does not receive any of the above funding

Is the participant enrolled in Medicaid?(Required)

Yes

Request

Nature of Request(Required)

Medical Equipment

Therapy Services

Both Equipment and Therapy

Please provide detail on the type of equipment or therapy you are seeking.(Orthopedic Equipment, Wheelchair, Therapy, Etc.)(Required)

Are you currently working with an equipment company or therapist?(Required)

Yes

What is the name of the equipment company or therapy provider?(Required)

Have you received financial assistance for adaptive equipment from another charity within the past 12 months?(Required)

Yes

Name of the charity/charities?(Required)

When did you receive this assistance?(Required)

Household Income Information

Number of earners in the household(Required)

Number of members in the household(Required)

Earner #1’s income per Year(Required)

Current Employer(Required)

Job Title(Required)

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Company Address

Street Address City State / Province / Region ZIP / Postal Code

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How long have you been employed by this employer?

Earner #2’s income per Year(Required)

Current Employer(Required)

Job Title(Required)

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Company Address

Street Address City State / Province / Region ZIP / Postal Code

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How long have you been employed by this employer?

Describe any extraordinary expenses or special circumstances. Be specific as to the expense and anticipated duration of the circumstances.

Please upload the first page of the most recent federal income tax return (Form 1040). This page should include Adjusted Gross Income and a list of dependents. If your household does NOT file taxes, but does receive SSI, please upload the most recent copy of the SSI Award letter.

You may choose to provide these documents later, but they are required to determine eligibility.

Most Recent Federal Income Tax Return

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

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Total Income

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Calculate your Monthly Income & Expenses

Variety prioritizes equipment and therapy requests from families with an Adjusted Gross Income of less than $85,000. Variety will consider requests from households with higher income on an individual basis. To be considered by Variety’s Review Team, please calculate and provide your monthly financial information below.

Monthly Take Home Income

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Earners #1 Monthly Income

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Earners #2 Monthly Income

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Social Security Income

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Child Support

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Total Income

Monthly Expenses

Home expenses

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Mortgage / Rent

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Phone

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Cable

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Other

Food expenses

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Groceries

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Special dietary food/supplements

Child related expenses

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Daycare/babysitting

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Other

Debt obligations

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Student loans

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Credit card loans

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Bank loans

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Medical bills

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Child support paid/alimony paid

Transportation expenses

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Car loans/public transportation costs

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Car insurance

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Gasoline

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Maintenance/repair

Health care expenses

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Health insurance (plan and HSA)

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Therapy/doctor visits

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Medicine

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Medical supplies

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Other

Other expenses

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Donations/charitable giving

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Savings/IRA

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Extracurricular activities

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Vacation

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Entertainment

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Personal

(haircuts/toiletries/ gifts/etc.)

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Petcare expenses

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Other

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Total monthly expenses

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Monthly Surplus

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Medical Personnel

Primary Care Physician and/or Therapist

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Name

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Name

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Medical Address 1

Street Address Address Line 2 City State ZIP Code

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Medical Address 2

Street Address Address Line 2 City State ZIP Code

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Phone

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Phone

Education

School Child Attends

School District Child Attends

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Names & Ages of Additional Children Residing in the Household

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Name

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Age

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Name

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Age

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Name

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Age

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Name

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Age

How did you hear about Variety?

Assessments

The funding of equipment/therapy would not be possible without many individuals, companies, and foundations within the Greater St. Louis community who contribute to Variety. Our programs depend on these benefactors.
With that in mind, you will be required to complete a survey to report how your child’s piece of equipment/therapy has impacted his/her life, and that of your family.
Your responses will be critical to increasing funding for Variety programs.

Consent(Required)

I acknowledge that I will be required to complete a survey if I am provided equipment / therapy.(Required)