Apply for help

How to apply:

Download and print the form and mail a copy to Help for Huntington’s KC, 3741 N Brighton Ave, Kansas City, MO 64117
Fill out the online form below
Download the form, complete it, and email a copy to rosalie@h4hkc.org

Download the PDF application

Download the .doc application

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This field is for validation purposes and should be left unchanged.

Name*

First Last

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Email*

Enter Email Confirm Email

If you or your loved one have been officially diagnosed with HD, when did that diagnosis occur and who diagnosed you/him/her?:

Is your request for assistance urgent?

Yes

Please explain why or why not:

How will the assistance impact your daily life?

Have you been turned down by another organization?

Yes

Is it possible to match our gift (church, family, etc)?

Yes

What type of assistance is needed (indicate all and any others):

Info about Huntington’s Disease

Financial assistance

Food or nutritional assistance

A household item

A safety-related item

Help caring for myself

Referral to a doctor

Referral to someone I can just talk to

Assistance with household tasks

Help caring for my loved one

Mental-health assistance

I want to feel useful in the fight against this disease

Other

If other, please describe:

Do you have a doctor, nurse, volunteer or other individual helping you address the medical needs of you or your loved one? If not, would you like help?

Have you explored options for ongoing funding and support such as Medicaid, long term care insurance, health insurance, hospice care, etc. If not, do you need help exploring these possible opportunities?

References: (please list non-family members only and give names and telephone numbers) 

Help for Huntington's Kansas City
3741 N Brighton Ave
Kansas City, MO 64117

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