Financial Assistance Application

Apply for Assistance

The Odone Family Support Program was launched in 2015 to provide financial assistance to low-income families living with adrenoleukodystrophy (ALD), adrenomyeloneuropathy (AMN), and other leukodystrophies. We also offer travel scholarshipse.g. in-person medical consultations, medical transportation, travel to conferences, etc.

If you (or your dependent) suffer(s) from ALD, AMN, or another leukodystrophy and need(s) help paying costs associated with medical care and/or living expenses, we can provide financial assistance based on your eligibility and income.

Note: All attachments MUST be in .PDF format.

If you have any questions or comments regarding the application process, please contact us.

Patient's First Name

Patient's Last Name

Applicant's First Name

Applicant's Last Name

Relation to Patient

Home Address

City

State

Zip Code

Country

Email Address

Phone

Patient's Date of Birth

Please attach a photo (PDF format only) of the patient/applicant

(Note: .PDF format only)

Total Annual Household Income (in US Dollars)
$.00

Please attach proof of income (e.g. pay stub, W-2, and/or income tax return)

(Note: .PDF format only)

Total Annual Public Assistance (e.g. Social Security, Disability, etc.)
$.00

Please attach proof of public assistance

(Note: .PDF format only)

Total Bank/Investment Assets (e.g. checking, savings, stocks, 401k, etc.)
$.00

Please attach recent bank statement(s) and/or document(s) relating to your investments/other assets.

(Note: .PDF format only)

Have you made a request for assistance for this need to any other organization/foundation within the last calendar year?
YesNo

If you answered yes to the previous question, please provide a detailed list of the foundations/organizations to which you have made these requests and their outcome.

Have you made a request for assistance for this need to any local, state, or federal entities within the last calendar year?
YesNo

Please attach financial assistance denial letter(s) if applicable (From government, health insurance company, and/or organization/foundation).

(Note: .PDF format only)

If you are approved for financial assistance, please provide a basic budget and description of how the funds would be used.

Please attach any estimate(s) and/or receipt(s) related to this funding request.

(Note: .PDF format only)

Patient Diagnosis
Adrenoleukodystrophy (ALD)Adrenomyeloneuropathy (AMN)Alexander's DiseaseMetachromatic Leukodystrophy (MLD)Krabbe's LeukodystrophyPelizaeus-Merzbacher Leukodystrophy (PMD)Unknown LeukodystrophyOther

Neurologist/Pediatrician

Medical Insurance

Please attach disease diagnosis letter (PDF format only) from doctor/medical center

(Note: .PDF format only)

Please write a cover letter describing the applicant/patient's personal story. Be sure to include how financial assistance could help you and/or the applicant, and where funds are needed most.

How did you hear about us?

I understand that the information I am giving will be verified by the The Myelin Project, state and/or federal enforcement agencies and others as required. I certify that the above information is true and accurate to the best of my knowledge. Should this request be granted, I give The Myelin Project permission to use any photos or statements regarding this request and I agree to provide a testimonial statement to The Myelin Project for publicity purposes.

*** Note: All attachments MUST be in .PDF format ***

If you have any questions or comments regarding the application process, please contact us.