Financial Assistance Application

Apply for Assistance

 Odone Family Support Program Application

The Odone Family Support Program was launched in 2015 to support low-income families living with adrenoleukodystrophy (ALD) and adrenomyeloneuropathy (AMN). We are committed to lessening the financial burden of care while providing comfort to patients and their families with food, medical supplies not covered insurance, out-of-pocket medical expenses, utility bill payments, etc. We also offer travel scholarships for patient families in need of assistance to attend medical conferences. To date, we have granted over $25,000 to ALD and AMN families in need.

The Myelin Project encourages residents of the United States and Canada to apply for financial assistance if you (or your dependent) suffer(s) from ALD and/or AMN and need(s) help paying costs associated with medical care and/or living expenses. Through the Odone Family Support Fund, we can provide financial assistance based on your eligibility and income. If you are an ALD or AMN patient and/or a family member of a ALD or AMN patient with low-income and would like to apply for financial assistance, please fill out the application.

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

Email Address

Phone

Patient's Date of Birth

Patient's Race/Ethnicity
 African-American Asian Caucasian Hispanic/Latino Native American Native Hawaiian Other

Please attach a photo of the patient/applicant

Total Annual Household Income
$.00

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

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

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

(Note: .PDF format only)

Have you made a request for assistance for this need to any other foundation within the last calendar year?
 Yes No

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.

Patient Diagnosis
 Adrenoleukodystrophy (ALD) Adrenomyeloneuropathy (AMN) Alexander's Disease Metachromatic Leukodystrophy (MLD) Krabbe's Leukodystrophy Pelizaeus-Merzbacher Leukodystrophy (PMD) Unknown Leukodystrophy Other

Neurologist/Pediatrician

Medical Insurance

Please attach disease diagnosis letter 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.