Name: EMST 75
SKU: 2387
Availability: InStock

Please note that we are currently operating at capacity, and any recent/new applications may be subject to a waitlist.

Application Status

Waitlist

Recipient's Name *

Pediatric or Adult? *

Parent's Name(s)

Date of Birth *

Current Age *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Your, or Parent's, Occupation(s) (if applicable) *

Emergency Contact *

Name, Relationship, Address, Email, and Phone #

Who is Your or Your Child's Primary Care Doctor? *

Referring Doctor (if any)

Who is your Speech-Language Pathologist? *

Please include full name, business address, and phone #

Current dysphagia-related diagnoses (and any significant co-existing conditions) *

Example: Stroke, Multiple Sclerosis, ALS, Down's Syndrome, Premature Birth, Failure to Thrive, etc....

Date of most recent medical appointment for dysphagia/swallowing *

Have you, or your child, had an instrumental swallowing assessment: *

Upload Most Recent Swallowing Report *

Click or drag a file to this area to upload.

(Failure to include instrumental swallow evaluation [MBSS/FEES] may result in delayed application processing.)

Family Annual Gross Income *

(Proof of income is required.)

Upload Proof of Income: W-2, Form 1040, Medicaid Eligibility Letter, Employer Letter, or Self-Certification letter *

Click or drag files to this area to upload. You can upload up to 5 files.

(Failure to include proof of income may result in delayed application processing.)

Number of family members in household *

Product(s) Requested *

Select all that you are requesting

Describe why you need these specific products: *

(attaching treating doctors order/prescription, if available in next space)

Additional Documents

Click or drag a file to this area to upload.

For any questions regarding the status of your application or to request additional product upon your application approval, please email our operations specialist at foodbank@dysphagiaoutreach.org. *

Yes
No

* I acknowledge that I understand how to contact The Dysphagia Outreach Project with questions, concerns, or to request more supplies.

Are you assisting the recipient named above to complete this application? If so, please provide your name.

I acknowledge that I have read the Adult Waiver of Liability in full (using the link below).

OPEN IN A NEW BROWSER WINDOW TO AVOID LOSING APPLICATION PROGRESS.

(If you're on a mobile device, press and hold down the link and an option to open in a new tab should pop up. For computer users, right click on the link and select "open in new tab") *

dysphagiafoodbank.org/adult-waiver/

I acknowledge that I have read the Pediatric Waiver of Liability in full (using the link below).

OPEN IN A NEW BROWSER WINDOW TO AVOID LOSING APPLICATION PROGRESS.

(If you're on a mobile device, press and hold down the link and an option to open in a new tab should pop up. For computer users, right click on the link and select "open in new tab") *

dysphagiafoodbank.org/pediatric-waiver/

By typing in your full name here, you indicate that you have read the waiver of liability and agree to all terms and conditions as set forth by Dysphagia Outreach Project for participation in the dysphagia food bank program.*

Apply For Assistance

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