Application Duchenne Assistance Application Duchenne Assistance Application "*" indicates required fields Step 1 of 9 – Start Here 11% How did you hear about us?FriendInternet SearchMDA/DND ClinicSocial MediaSocial WorkerOtherDoes the person this application applies to have a confirmed diagnosis of Duchenne muscular dystrophy? Yes No What mobility device is the person with DMD using?What is the timeframe that you are hoping to receive the device you are requesting?Besides Duchenne, does your child have any other diagnosis? Yes No My relationship to the individual can best be described as: Self Caregiver to minor Caregiver to adult Person with DuchenneName* First Last Date of Birth* MM slash DD slash YYYY Age*Please enter a number from 0 to 100.Is this person a legal U.S. Resident? Yes No Parent/Legal Guardian of Duchenne PatientAre you a single parent/sole caregiver* Yes No Name* First Last Are you a legal U.S. resident?* Yes No Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you have other children? Yes No How many and what ages?Occupation*Spouse OccupationSpouse IncomeYearly income before taxes: (we may need further information such as a W2, previous years taxes, etc)* YOU MUST INCLUDE DIAGNOSIS CONFIRMATION FROM DOCTOR OR DMD CLINICMax. file size: 32 MB.Name of Primary PhysicianPhoneEmail Name of Muscular Dystrophy specialist and/or muscular dystrophy clinicName of Medical Center/Muscular Dystrophy Clinic Which services are you interested in? Help in purchasing a *Handicap Accessible Van Medical Device Medical Transportation Expenses In-home ramp(s) Other What are your needs and how will this help the person with Duchenne and their family?*FOR REQUEST WITH HELP WITH A HANDICAP ACCESSIBLE VAN – READ BELOW CAREFULLY IF YOU ARE APPROVED: Walking Strong provides an $10,000 down payment for a handicap accessible van using our national preferred vendor that sells new and pre-owned accessible vans. It is up to YOU to decide what you can afford and will work with the van company directly on financing as well as warranties. YOU will be responsible for ANY/ALL TAXES, TITLE AND REGISTRATION FEES, and anything that occurs with the van after received. Should you have an extraordinary circumstance, and are not able to afford a van please let us know. The aforementioned is based upon application approval along with the proper insurance documentation. Have you exhausted all other forms of assistance? Example: Insurance, Statewide services, etc. Yes No Have you applied to any other Duchenne Organization for assistance? if so, which one?* Yes No What other Duchenne Assistance program have you applied to? Select all that apply: Private (ACA plan, employer plan or independent plan) Medicaid (Medical assistance) Medicare Other None (You have no insurance) Insurance Plan(s)Car Insurance Company(s)Are you receiving aid from the state, Medical/Medicaid, waiver programs etc?* Yes No Other Coverage (e.g. Medicaid Waiver, state assistance, TEFRA, other)Does the DMD patient qualify under regional center?* Yes No I am not sure YOU MUST INCLUDE LETTER OF NECESSITY FROM YOUR PHYSICIAN OR DMD CLINIC. YOUR APPLICATION WILL NOT BE REVIEWED WITHOUT IT.Max. file size: 32 MB. Do we have permission to contact you for more information? Yes No Do we have permission to contact you for more information?What is the best time/day to contact you? (Please provide your time zone) All transactions and conversations between you (APPLICANT and RECEIVER) and Walking Strong is to remain CONFIDENTIAL Should you receive Assistance, no details of transaction be disclosed at any time, which includes the amount of award/gift, conversations, emails etc.All transactions and conversations between you (APPLICANT and RECEIVER) and Walking Strong is to remain CONFIDENTIAL Should you receive Assistance, no details of transaction be disclosed at any time, which includes the amount of award/gift, conversations, emails etc. I Agree This Release and Waiver of Liability ("Release”) is executed as of by the applicant ("Beneficiary”) or the parent or legal guardian of the Beneficiary, in favor of Walking Strong, Inc., a California nonprofit corporation, its directors, officers, employees, and agents. The Beneficiary has applied for [___________] (the "Particular(s)”) from Walking Strong, Inc. Definitions: "Beneficiary" – an individual afflicted with Duchenne Muscular Dystrophy ("DMD”) and appurtenant symptoms that receives Particulars, as defined hereinbelow, from Walking Strong, Inc. to assist with costs of treatment or hardship expenses, mobility, sports, and performance of daily tasks. "Particulars” – Mobility aids including but not limited to wheelchairs, scooters, lifts, walkers; cognitive aids including but not limited to computer or electrical assistive devices, screens, and readers; physical modifications to the surrounding environment including but not limited to ramps, wider doorways, grab bars; lightweight high performance mobility devices for sports; adaptive devices to assist with tasks such as eating, playing games, dressing, grooming etc.; a handicapped accessible vehicle "Walking Strong, Inc.” – is a not-for-profit Corporation registered in the State of California and by the IRS as a 401(c)(3) company, that priveds cash disbursement and Particulars as defined hereinabove to individuals afflicted with DMD, as well as raises money for clinical trials and research for DMD. In consideration of receiving Particulars provided by Walking Strong, Inc. the Beneficiary hereby freely, voluntarily and without duress agrees to the following terms: 1. Release and Waiver. To the fullest extent permitted by law Beneficiary hereby releases and forever discharges and holds harmless Walking Strong, Inc., and its’ past, present and future agents, employees, officers, directors, board members, representatives, affiliates, partners, attorneys successors and assigns, from any and all liability and from any and all past, present or future claims, demands, lawsuits, obligations, actions, causes of action, injuries, death, fines, penalties, judgments, settlements, rights, damages, costs (including the payment of reasonable attorney fees and litigation expenses), loss of services of whatever kind or nature, either in law or in equity, that arise or may hereafter arise from Beneficiary’s Particular(s), or interaction with a vendor or service provider funded by Walking Strong, Inc. on Beneficiary’s behalf. A. Beneficiary, or the parent or guardian of the beneficiary must register and license the vehicle with their local Department of Motor vehicles; B. Beneficiary or the parent or guardian of the Beneficiary must maintain basic liability insurance coverage and name Walking Strong, Inc. as an additional insured; C. Beneficiary agrees that he will not use said vehicles, cause or permit the same to be used in any manner whatsoever in violation or contravention of any Municipal, County, State or Federal Law, ordinance or regulation; D. Beneficiary waives any claim which may hereafter arise for any and all damage he/she may hereafter sustain by reason of any action, civil or criminal, which Walking Strong, Inc. may take in connection with the Beneficiary’s retention of the subject vehicle in the event of Beneficiary’s failure to return said vehicle to Walking Strong, Inc. as specified in this paragraph; E. Beneficiary agrees that none of the authorized drivers will operate the vehicle while under the influence of alcohol or narcotics. 5. Medical Treatment. Beneficiary hereby releases and forever discharges Walking Strong, Inc. from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with the Beneficiary’s Particular(s) funded by a Gift from Walking Strong, Inc. 6. Insurance. Beneficiary understands that Walking Strong, Inc. does not carry or maintain health, medical, or disability insurance coverage for any Beneficiary. Each Beneficiary is expected and encouraged to obtain his or her own medical or health insurance coverage. 7. Effective Date. The effective date of this Release shall be retroactive to the date Walking Strong, Inc. first engaged with Beneficiary to discuss providing Particulars to Beneficiary as a one time event. Should Walking Strong elect not to provide Particulars for any reason, the Beneficiary shall have no claim against Walking Strong, Inc. 8. Binding Arbitration. The Parties agree that any controversy or claim arising out of, or relating to, this Release, including any claim against Walking Strong, Inc. or any aspect of the Particulars provided, or that have been provided, shall be resolved by first utilizing methods of alternative dispute resolution. Specifically, the Parties agree that they will first submit any dispute that they may have to non-binding mediation which shall be held at the Judicial Arbitration and Mediation Services ("JAMS”) in Los Angeles, California. If the Parties are unable to resolve their dispute by mediation then the Parties are required to submit the dispute to binding arbitration before the Judicial Arbitration and Mediation Services in Los Angeles, California. Said arbitration shall be conducted before a retired judge. The parties shall have the right to conduct discovery, in relation to the arbitration. To the extent that any portion of this paragraph conflicts with any rule of the Judicial Arbitration and Mediation Services, this paragraph will be deemed controlling. In all other aspects the rules of the Judicial Arbitration and Mediation Services shall govern the conduct of the arbitration. The Parties hereby consent to jurisdiction in California, and each Party shall bear its own fees and costs at each and every stage of any alleged dispute. BENEFICIARY SPECIFICALLY WAIVES ANY RIGHT HE/SHE MAY HAVE TO TRIAL BY JURY OF ANY CAUSE OF ACTION, CLAIM, CROSS-CLAIM, COUNTERCLAIM, THIRD PARTY CLAIM OR ANY OTHER CLAIM (COLLECTIVELY, "CLAIMS”) AND AGREES THAT ALL CONTROVERSIES AND CLAIMS CAN BE RESOLVED BY BINDING ARBITRATION. 9. Modification. Any modification or subsequent agreement must be in writing and signed by all Parties. Any headings preceding the several Sections hereof are inserted solely for convenience of reference and shall not themselves constitute a part of this Agreement, nor shall they affect its meaning, construction, or effect. 10. Assignment. The respective rights and obligations of the Parties to this Release may not be assigned by any Party without the prior written consent of the other. 11. Integrated Agreement. All prior and contemporaneous conversations, negotiations, representations, covenants, consents, contracts, and warranties with respect to the conduct contemplated by this Release are waived, merged, and superseded. This is an integrated Release and to the extent any prior or contemporaneous conversations, negotiations, representations, covenants, consent forms, contracts, and/or warranties with respect to the conduct contemplated by this Release are inconsistent or conflict with the terms of this Release, then this Release shall govern. 12. Governing Law; Validity. This Release shall be governed by and interpreted in accordance with the laws of the State of California, without regard to conflict of law principles. Beneficiary agrees that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release, which shall continue to be enforceable. 13. Beneficiary Under 18. If the Beneficiary is younger than 18 years old, then the person acknowledging this Release certifies that he or she is the parent or legal guardian of the Beneficiary and does hereby give this Release without reservation on behalf of the Applicant. 14. Agency. No agency, partnership, employment or joint venture is created or intended to be created between the Parties herein. 15. Severability. In the event any of the provisions, whether sentences or entire Paragraphs, of this Release are deemed to be invalid or unenforceable, the same shall be deemed severable from the remainder of this Release. If such provision shall be deemed invalid due to its scope or breadth such provision shall be deemed valid to the extent of the scope or breadth permitted by law. 16. Disclaimers. Nothing in this Release shall be construed as a representation, guaranty or warranty by Walking Strong, Inc. (i) that any Particular provided, used, donated or otherwise is or will be free from defect; (ii) regarding the effectiveness, value, safety, or non-toxicity of any Particular; or (iii) that any particular will work as advertised or otherwise assist the Beneficiary as intended. Beneficiary accepts the particulars offered by Walking Strong, Inc. with the knowledge and express understanding that Walking Strong, Inc. makes no warranties or guarantees and expressly disclaims, waives, releases and renounces all warranties, express or implied, including, including but not limited to, warranties of merchantability or fitness for a particular purpose, and all warranties arising from any course of dealing or performance or usage of trade. The Beneficiary further expressly understands and agrees that Walking Strong, Inc. does not guaranty any particular tax characterization of any donations or benefits conferred hereunder or in connection herewith. Beneficiary understands that any and all tax liability incurred as a result of this Release is his/her own responsibility and duty. I/We have read and understand the foregoing terms and provisions that he or she has relied upon the representations set forth in this Agreement, and that he or she is signing this Agreement freely and voluntarily.and agree to same. If more than one party signs below, we each agree to be liable, jointly and severally, under the terms and provisions of this agreement. WALKING STRONG, INC., A California nonprofit corporationThis Release and Waiver of Liability (“Release”) is executed as of by the applicant (“Beneficiary”) or the parent or legal guardian of the Beneficiary, in favor of Walking Strong, Inc., a California nonprofit corporation, its directors, officers, employees, and agents. The Beneficiary has applied for [___________] (the “Particular(s)”) from Walking Strong, Inc. Definitions: “Beneficiary” – an individual afflicted with Duchenne Muscular Dystrophy (“DMD”) and appurtenant symptoms that receives Particulars, as defined hereinbelow, from Walking Strong, Inc. to assist with costs of treatment or hardship expenses, mobility, sports, and performance of daily tasks. “Particulars” – Mobility aids including but not limited to wheelchairs, scooters, lifts, walkers; cognitive aids including but not limited to computer or electrical assistive devices, screens, and readers; physical modifications to the surrounding environment including but not limited to ramps, wider doorways, grab bars; lightweight high performance mobility devices for sports; adaptive devices to assist with tasks such as eating, playing games, dressing, grooming etc.; a handicapped accessible vehicle “Walking Strong, Inc.” – is a not-for-profit Corporation registered in the State of California and by the IRS as a 401(c)(3) company, that priveds cash disbursement and Particulars as defined hereinabove to individuals afflicted with DMD, as well as raises money for clinical trials and research for DMD. In consideration of receiving Particulars provided by Walking Strong, Inc. the Beneficiary hereby freely, voluntarily and without duress agrees to the following terms: 1. Release and Waiver. To the fullest extent permitted by law Beneficiary hereby releases and forever discharges and holds harmless Walking Strong, Inc., and its’ past, present and future agents, employees, officers, directors, board members, representatives, affiliates, partners, attorneys successors and assigns, from any and all liability and from any and all past, present or future claims, demands, lawsuits, obligations, actions, causes of action, injuries, death, fines, penalties, judgments, settlements, rights, damages, costs (including the payment of reasonable attorney fees and litigation expenses), loss of services of whatever kind or nature, either in law or in equity, that arise or may hereafter arise from Beneficiary’s Particular(s), or interaction with a vendor or service provider funded by Walking Strong, Inc. on Beneficiary’s behalf. A. Beneficiary, or the parent or guardian of the beneficiary must register and license the vehicle with their local Department of Motor vehicles; B. Beneficiary or the parent or guardian of the Beneficiary must maintain basic liability insurance coverage and name Walking Strong, Inc. as an additional insured; C. Beneficiary agrees that he will not use said vehicles, cause or permit the same to be used in any manner whatsoever in violation or contravention of any Municipal, County, State or Federal Law, ordinance or regulation; D. Beneficiary waives any claim which may hereafter arise for any and all damage he/she may hereafter sustain by reason of any action, civil or criminal, which Walking Strong, Inc. may take in connection with the Beneficiary’s retention of the subject vehicle in the event of Beneficiary’s failure to return said vehicle to Walking Strong, Inc. as specified in this paragraph; E. Beneficiary agrees that none of the authorized drivers will operate the vehicle while under the influence of alcohol or narcotics. 5. Medical Treatment. Beneficiary hereby releases and forever discharges Walking Strong, Inc. from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with the Beneficiary’s Particular(s) funded by a Gift from Walking Strong, Inc. 6. Insurance. Beneficiary understands that Walking Strong, Inc. does not carry or maintain health, medical, or disability insurance coverage for any Beneficiary. Each Beneficiary is expected and encouraged to obtain his or her own medical or health insurance coverage. 7. Effective Date. The effective date of this Release shall be retroactive to the date Walking Strong, Inc. first engaged with Beneficiary to discuss providing Particulars to Beneficiary as a one time event. Should Walking Strong elect not to provide Particulars for any reason, the Beneficiary shall have no claim against Walking Strong, Inc. 8. Binding Arbitration. The Parties agree that any controversy or claim arising out of, or relating to, this Release, including any claim against Walking Strong, Inc. or any aspect of the Particulars provided, or that have been provided, shall be resolved by first utilizing methods of alternative dispute resolution. Specifically, the Parties agree that they will first submit any dispute that they may have to non-binding mediation which shall be held at the Judicial Arbitration and Mediation Services (“JAMS”) in Los Angeles, California. If the Parties are unable to resolve their dispute by mediation then the Parties are required to submit the dispute to binding arbitration before the Judicial Arbitration and Mediation Services in Los Angeles, California. Said arbitration shall be conducted before a retired judge. The parties shall have the right to conduct discovery, in relation to the arbitration. To the extent that any portion of this paragraph conflicts with any rule of the Judicial Arbitration and Mediation Services, this paragraph will be deemed controlling. In all other aspects the rules of the Judicial Arbitration and Mediation Services shall govern the conduct of the arbitration. The Parties hereby consent to jurisdiction in California, and each Party shall bear its own fees and costs at each and every stage of any alleged dispute. BENEFICIARY SPECIFICALLY WAIVES ANY RIGHT HE/SHE MAY HAVE TO TRIAL BY JURY OF ANY CAUSE OF ACTION, CLAIM, CROSS-CLAIM, COUNTERCLAIM, THIRD PARTY CLAIM OR ANY OTHER CLAIM (COLLECTIVELY, “CLAIMS”) AND AGREES THAT ALL CONTROVERSIES AND CLAIMS CAN BE RESOLVED BY BINDING ARBITRATION. 9. Modification. Any modification or subsequent agreement must be in writing and signed by all Parties. Any headings preceding the several Sections hereof are inserted solely for convenience of reference and shall not themselves constitute a part of this Agreement, nor shall they affect its meaning, construction, or effect. 10. Assignment. The respective rights and obligations of the Parties to this Release may not be assigned by any Party without the prior written consent of the other. 11. Integrated Agreement. All prior and contemporaneous conversations, negotiations, representations, covenants, consents, contracts, and warranties with respect to the conduct contemplated by this Release are waived, merged, and superseded. This is an integrated Release and to the extent any prior or contemporaneous conversations, negotiations, representations, covenants, consent forms, contracts, and/or warranties with respect to the conduct contemplated by this Release are inconsistent or conflict with the terms of this Release, then this Release shall govern. 12. Governing Law; Validity. This Release shall be governed by and interpreted in accordance with the laws of the State of California, without regard to conflict of law principles. Beneficiary agrees that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release, which shall continue to be enforceable. 13. Beneficiary Under 18. If the Beneficiary is younger than 18 years old, then the person acknowledging this Release certifies that he or she is the parent or legal guardian of the Beneficiary and does hereby give this Release without reservation on behalf of the Applicant. 14. Agency. No agency, partnership, employment or joint venture is created or intended to be created between the Parties herein. 15. Severability. In the event any of the provisions, whether sentences or entire Paragraphs, of this Release are deemed to be invalid or unenforceable, the same shall be deemed severable from the remainder of this Release. If such provision shall be deemed invalid due to its scope or breadth such provision shall be deemed valid to the extent of the scope or breadth permitted by law. 16. Disclaimers. Nothing in this Release shall be construed as a representation, guaranty or warranty by Walking Strong, Inc. (i) that any Particular provided, used, donated or otherwise is or will be free from defect; (ii) regarding the effectiveness, value, safety, or non-toxicity of any Particular; or (iii) that any particular will work as advertised or otherwise assist the Beneficiary as intended. Beneficiary accepts the particulars offered by Walking Strong, Inc. with the knowledge and express understanding that Walking Strong, Inc. makes no warranties or guarantees and expressly disclaims, waives, releases and renounces all warranties, express or implied, including, including but not limited to, warranties of merchantability or fitness for a particular purpose, and all warranties arising from any course of dealing or performance or usage of trade. The Beneficiary further expressly understands and agrees that Walking Strong, Inc. does not guaranty any particular tax characterization of any donations or benefits conferred hereunder or in connection herewith. Beneficiary understands that any and all tax liability incurred as a result of this Release is his/her own responsibility and duty. I/We have read and understand the foregoing terms and provisions that he or she has relied upon the representations set forth in this Agreement, and that he or she is signing this Agreement freely and voluntarily.and agree to same. If more than one party signs below, we each agree to be liable, jointly and severally, under the terms and provisions of this agreement. WALKING STRONG, INC., A California nonprofit corporation I Accept and Agree to the Above TermsNameThis field is for validation purposes and should be left unchanged.
