APPLY

WHO IS ELIGIBLE

Must be female, age 16 or older.
Must be a U.S. Citizen.
Must have loss of one or more limbs.
Must fill out the application in its entirety.
Must have exhausted all insurance funding resources.
Must be presently wearing an arm (passive) or leg prosthesis on a daily basis or be in the process of being fitted by a certified prosthetist.
Must be able to travel to Dallas, Texas for a 2-3 day appointment with our provider.

Name (First, Middle, Last)

First Name

Last Name

Age

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone Number

Marital Status

Single

Married

Occupation

Student

Do you have children?

Please give us a detailed description of your limb loss, including how it happened, which limb(s), and where amputated etc.

When did you lose your limb(s)?

YYYY

Tell us about any other surgeries you have had on your limb/s other than the initial amputation/s if applicable:

Do you currently wear a prosthesis?

If so, how many do you have?

How long have you had it/them?

Do you have insurance that covers any of your prothetic needs?

How often do you wear a prosthesis?

Please provide the name & address of your prosthetist.

Why do you desire to have a silicone covering for your prosthesis?

If you qualify to be a beneficiary of the Lauren Scruggs Kennedy Foundation, do you plan to travel to Dallas for meetings with our providers?

Is there anything else you would like for us to know about you?

How did you hear about The Lauren Scruggs Kennedy Foundation?

To complete your application process, please email the following photos to info@lskfoundation.com:

1. A photo of you wearing your prosthesis

2. A close up photo/s of your prosthesis