Financial Assistance Application

At Addi Jo’s Footprints, we understand the financial challenges that can arise when caring for a child with special needs. Our Financial Assistance Program aims to provide support to families facing the financial burdens associated with medical bills, therapies, and essential equipment.

To begin the financial assistance application process, please fill out the form linked below. We recognize that each family’s situation is unique, and we are committed to reviewing applications with care and confidentiality.

Financial Assistance Application

Who Can Benefit

Children (birth to age 18) with a condition that causes intellectual or physical disabilities that affect his/her ability to perform certain everyday tasks (i.e. genetic syndromes, autism, global development delay)

Children must be from one of the parishes listed below in the application section.

Examples of services/equipment that we can provide assistance with include but are not limited to: communication devices, adaptive equipment, speech/occupational/physical therapy. All must be denied or not fully covered by insurance plans.

We may request proof of denial and other additional information before approving your application.

Payouts will be made to the business or provider that you are requesting services or equipment from and will be on a case-by-case basis depending on our current level of funding and after approval from our board.

If approved, we do ask for you to submit a picture and brief write up of your child for our social media outlets. This is optional but it allows our supporters to see how our funding is used which adds to the growth and success of our organization.

Examples of conditions that we DO NOT provide assistance with include but are not limited to: isolated language, speech, and fine motor delays, and/or sensory processing disorders that are not linked to a specific diagnosis such as autism, CP, various syndromes etc., behavioral conditions such as ADD/ADHD, and isolated learning disorders such as dyslexia.

Examples of services that we do NOT provide assistance with include but are not limited to equine therapy, vision therapy, tutoring, and parent education classes.

While we wish we could help ALL children struggling with different abilities, we have decided to focus on a specific population due to the number of applicants, funding, and the size of our organization.

"*" indicates required fields

Child's Name*

First Last

Child's DOB*

Child's Age*

Name of Parent/Guardian*

First Last

Email*

Phone*

Best Time To Contact You?*

Any child (birth to age 18) diagnosed with a developmental disability that impairs their physical and/or mental ability to perform tasks of everyday life and resides in one of the following parishes:*

Have you received assistance from Addi Jo’s Footprints in the past year?*

Yes

Has your child been given a diagnosis deeming them having special or unique needs that affect his/her ability to perform certain everyday tasks - various syndromes, autism, global delay, etc? *

Yes

Current Insurance Coverage*

Where Does Your Child Currently Receive Therapy?*

Brief description of patient’s medical diagnosis and equipment/services required on daily basis*

Mailing Address*

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

Amount of Funding Requested*

Use of Funding*

By submitting this application, you are providing honest & accurate information. If you accept the financial assistance, you also agree to allow Addi Jo’s Footprints to share your story and experience and agree to send photos that we can use on our social media page, website, and any other media outlets that we utilize to promote our nonprofit.*

I agree

I disagree

We regret to inform you that if you have selected “No” under the field “Has your child been given a diagnosis deeming them having special or unique needs that affect his/her ability to perform certain everyday tasks – various syndromes, autism, global delay, etc? *“, we are not able to provide assistance for your child at this time.