DUCHENNE ASSISTANCE APPLICATION

Please fill out this form in full and attach the proper documentation. Upon receiving your completed application, someone from Walking Strong will contact you for further information and/or to let you know if your application is approved.

1 Please Start Here



YesNo


SelfCaregiver to minor (<18)Caregiver to Adult

Person with Duchenne




2 Person filling out this application












3 Medical information





4 What are your needs?

Help in purchasing a *Handicap Accessible VanMedical DeviceMedical Transportation ExpensesIn-home ramp(s)Other


*Please note that Walking Strong typically provides an $8,000 downpayment for a handicap accessible van using our preferred vendor selling 4-5 year old accessible vans with manual ramp. Should you have an extraordinary circumstance, and are not able to afford a van please let us know. Also, if you also wish to purchase a van from a particular dealership, the downpayment will be wired directly to the dealer. The aforementioned is based upon application approval along with the proper insurance documentation.

5 Insurance information


Private (ACA plan, employer plan or independent plan)Medicaid (Medical assistance)MedicareOtherNone (You have no insurance)



6 Documentation

Please upload all documents related to your application here (e.g. letter of medical necessity, insurance denial, appeals, quotes and estimates, personal letter of need, estimate from vendor/van dealership website link to order, and vendor contact information, etc.)
Feel free to black out any personal information.

7 How to contact you


YesNo


8 RELEASE AND WAIVER OF LIABILITY 

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 corporation 

I accept the Authorization to Disclose Health Information

Contact Us

Please fill out the form below with any questions or concerns and we will get back to you shortly.

Not readable? Change text. captcha txt

Start typing and press Enter to search