Assistance Program

Sister-Bear, a tax-exempt non-profit foundation, is dedicated to the following mission:

Our mission is to provide hope and independence through neuro rehab and wellness resources for adults living with a neurological injury or illness.

Instructions for Financial Assistance Application:

To apply for financial assistance from the Sister-Bear Foundation, please complete and submit the application along with the required documents. Applications for financial assistance are reviewed by the Sister-Bear Foundation Committee on a quarterly basis. Assistance funds are awarded based on availability of funds and at the sole discretion of the Sister-Bear Committee and Sister-Bear Board of Directors. All applicants will be contacted following review of their application.

Eligibility:

Applicants must be 18 years and older.
Applicants must be diagnosed with a spinal cord illness/injury or another neurological accident or illness and are mobility impaired.
Applicants must reside in the top 26 counties of the Texas Panhandle or the surrounding four state area (Oklahoma, New Mexico, Kansas, Colorado).
All sections of the application must be completed, and all accompanying documents must be submitted prior to the Board reviewing the request.
Assistance may be requested one time during a fiscal quarter. Each request for assistance requires a new application submission.
Applicants must have financial need and may be asked to provide supporting financial documentation such as receipts, federal tax returns, SSI Benefits verification letters, etc.

Details:

Assistance funds are paid to the provider or for the resource directly. No funds are paid directly to the applicant.
Funding awards are cancelled if not used within one year from date of approval.

The following are expenses considered for, but not limited to:

Wheelchairs; Bath / Shower Chair; Wheelchair Accessory or Modification (i.e.: SmartDrive); Wheelchair Lifts; Vehicle Modifications (i.e.: hand controls, lifts); Driver Evaluations & Training; Specialty Beds & Mattresses; FES Equipment; Home Medical Supplies (i.e.: catheters, adult diapers, mattress pads); Patient Lifts, Home Modifications (i.e.: ramps, bathroom, hallway, etc.); Prescription Medications; Therapeutic, Medical and Rehabilitation Services (i.e.: Voice therapy, Occupation, Physical, Aquatic, Equine, Massage, Rolfing, Acupuncture, etc.); Travel Expenses incurred to travel to Therapeutic, Medical, and Rehabilitation Services (i.e.: gas, hotel, food, etc.); Service Animals (i.e.: Service animal, training); Support Groups for Caregivers / Counseling / Mental Health Therapy.

Expenses Not covered by this Grant are, but not limited to, the following:

Computer, Cell Phone, Living Expenses (i.e.: Rent, Utilities, etc.), or Mileage.

Required Documents:

The application must be accompanied by a signed letter from applicant’s treating physician on that physician’s letterhead stating the applicant’s full name, date of birth and diagnosis.
Provide documentation showing denial from insurance company (if applicable).
Receipt(s) for expenses incurred within the last 3 months (if applicable).
Documentation of expected expenses related to the list above.

Please contact Sister-Bear Wellness Program Committee representative, at programs@sister-bear.com with questions concerning the application process.

If you would prefer to print and send the paper form, please click the button below for the printable PDF form.

Date of Application

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

If form is being completed by someone other than the requesting grantee, please list your name and relationship to the applicant.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Medical Diagnosis / Nature of Disability

Indicate the Type of Request

Equipment

Therapy / Treatment

Travel Expenses

Other

Equipment needed and cost

Travel expenses requested (please include the facility location, duration, and program)

Alternative treatment requested (Include provider name, type of treatment, cost, and duration)

Other expenses requested (Please include quotes, receipts, denial from insurance company)

Please provide a brief description of the applicant's situation and the benefits the requested will provide. Please indicate the family's ability and willingness to participate financially in the purchase if only partial funds can be granted.

Share how your injury or illness has changed your ability to work, socialize with friends and family, and live an independent life.

Describe your physical abilities you lost as a result of your injury or illness. What mobility do you have now?

Please explain whether you have tried to obtain coverage for this request through insurance.

Have you received compensation for your injury or illness?

Have you applied for grants from anyone else? If so, who and what is the status?

LIABILITY RELEASE, DISCLAIMER, & AUTHORIZATION TO USE NAME & LIKENESS:

In consideration of the receipt of a grant awarded by Sister-Bear Foundation, I the Recipient thereof, him/herself or through his/her legal guardian, hereby releases and forever discharges Sister-Bear Foundation, its officers, directors, employees, agents, affiliates and volunteers (hereafter collectively referred to as "Sister-Bear") from and against any and all claims, of any type, which arise from or are related to: 1. Any alleged malfunction of or defect in the enabling equipment; 2. Any allegation that the enabling equipment was not appropriate or suitable for the Recipient; 3. Any other matter, of any type, related, in any way, to the Recipient's receipt or use of the enabling equipment; 4. Any therapy/treatment complications or undesirable results; 5. Any allegation that the therapy/treatment was not what was expected; 6. Any other matter, of any type, related, in any way, to the Recipient's participation in travel or therapy/treatment; 7. Any matter, of any type, related, in any way, to any modifications made to the Recipient's property that was not what was expected. TO AGREE TO THE ABOVE STATEMENTS PLEASE TYPE YOUR FULL NAME IN THE SPACE BELOW:

ACCURACY OF INFORMATION:

I stipulate that the information included in this application is true to the best of my knowledge. Further, I understand that the presence of inaccurate information in this application could result in the need for re-evaluation of this application on the part of Sister-Bear. TO AGREE TO THE ABOVE STATEMENT PLEASE TYPE YOUR FULL NAME IN THE SPACE BELOW:

DISCLAIMER:

Part of the mission of Sister-Bear is to provide funding to help purchase specialized therapy devices and mobility equipment to those suffering from neurological injury or illness. Sister-Bear does not provide equipment, and as such, disclaims any and all liability for property damage and/or bodily injury resulting from the use of the equipment acquired with Sister-Bear funds. Sister-Bear disclaims any and all warranties with regard to the equipment acquired with Sister-Bear funds, including the merchantability and fitness for a particular purpose. Sister-Bear is merely a funding source. Sister-Bear is in no way responsible for reclaiming, disposing of, maintaining, or repairing equipment. It is the sole responsibility of the Recipient to maintain, repair, and/or dispose of the equipment. Any other costs that may be associated with the equipment such as installation, delivery, labor, disposal, etc. that are not explicitly stated on the application are the sole responsibility of the Recipient. All installations of ramps, lifts, stair glides, electrical supplies, etc. must be in compliance with applicable building codes. Sister-Bear is in no way responsible for ensuring compliance with any and all ordinances, codes, and laws. Before disbursement of any funds to purchase equipment, the Recipient must have this form signed and returned to Sister-Bear. TO AGREE TO THE ABOVE DISCLAIMER PLEASE TYPE YOUR FULL NAME IN THE SPACE BELOW:

AUTHORIZATION TO USE NAME AND LIKENESS:

The Recipient and his/her legal guardian hereby acknowledge and agree that acceptance of a grant from Sister-Bear Foundation may result in publicity. The Recipient and his/her legal guardian hereby irrevocably authorize Sister-Bear: a. The publicize and use the Recipient's likeness, voice, and features, with or without his/her name, for any publication, promotion, trade, or business use, or any other pupose; b. To photograph, videotape, film, and record each Recipient in any manner Sister-Bear Foundation chooses; c. To copyright, convey, or otherwise distribute now or in the future, any such material involving the Recipient, his/her legal guardian and that said material may be distributed to anyone, for any purpose, including the general public, magazines, newspapers, television, radio stations; d. To publicize, now or in the future, the name of the Recipient including information regarding his/her physical condition and details regarding the equipment, therapy/treatment, or services received from Sister-Bear Foundation; e. The Recipient and his/her legal guardian hereby releases Sister-Bear Foundation from and against any and all claims, of any type, which arise from or are related to Sister-Bear Foundation's use, distribution, or disclosure of any photographs, films, videotapes, electronic recording, or other information regarding the Recipient and the award from Sister-Bear Foundation. TO AGREE TO THE ABOVE STATEMENTS PLEASE TYPE YOUR FULL NAME IN THE SPACE BELOW:

How did you find out about Sister-Bear Foundation?

PLEASE MAKE SURE TO EMAIL ANY NECESSARY DOCUMENTS TO

programs@sister-bear.com

REQUIRED:

Include a signed letter from applicant’s treating physician on that physician’s letterhead stating the applicant’s full name, date of birth, and diagnosis.

-Provide documentation showing denial from insurance company.

-Receipt(s) for expenses incurred within the last 3 months.

-Documentation of expected expenses related to the list above.

PRINT THE ASSISTANCE APPLICATION

PLEASE MAKE SURE TO EMAIL ANY NECESSARY DOCUMENTS TO programs@sister-bear.com

Assistance Program

If you would prefer to print and send the paper form, please click the button below for the printable PDF form.

Hope is the anchor of the soul. ♡