Assistive Technology Hardship Award Application

Purpose: This form is for individuals seeking financial assistance from the Adaptive Technologies Hardship Fund, which supports the cost of adaptive technology for those in need. A portion of Adaptive Technologies’ sales funds this program.

Instructions: Please fill out this form to the best of your ability. If you need help, a caregiver or authorized representative may assist you.

"*" indicates required fields

Applicant Information

Full Name*

First Last

Address*

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Phone Number*

Email (if available)

Caregive/Authorized Representative (if applicable)

Relationship to Applicant

Hardship Information

Briefly describe your need for adaptive technology (e.g. type of device, such as a communication aid or home automation system)*

Explain your financial hardship (e.g. lack of insurance coverage, inability to pay co-pays, or other challenges)*

Current Funding Sources (check all that apply)*

Medicare

Medicaid

Medicaid Waiver

Private Insurance

Vocational Rehabilitation/OOD

None

Other (please explain)

Other Funding Source*

Additional Details

Estimated Dollar Cost of Technology (if known)*

Have you contacted Adaptive Technologies for funding assistance before?*

Yes (If yes, provide date or details)

No

Prior contact details*

Are you willing to participate in a brief interview or provide documentation (e.g., proof of income or medical need)?*

Yes

No

Acknowledgement and Signature

I certify that the information provided is true to the best of my knowledge. I understand that funds are limited and awards are subject to approval by Adaptive Technologies. I release Adaptive Technologies from liability related to the use or maintenance of any awarded technology, as outlined in the Customer Handbook.

Applicant or Authorized Representative Signature*

Date*

Month

Day

Year

Name

This field is for validation purposes and should be left unchanged.

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