Resources
One-Stop Resource Guide:
Looking for help? In addition to the many resources below, United Cerebral Palsy has developed comprehensive One-Stop Resource Guides to help you locate the assistance you need. These state-based Guides are free and can be downloaded as Microsoft Word® documents or as PDFs. Download the One-Stop Resource Guide for your state now: (Text, PDF)
In Kansas, the most comprehensive listing of available services is the “211” website, hosted by United Way of the Plains. This site allows the user to type in “Key” words such as “cerebral palsy”, “autism”, “child abuse”, “homeless” etc. And sort through available service providers by city, county or zip code.
UCP does not endorse, takes no responsibility for, and exercises no control over the referenced organization or its views, or contents, nor does it vouch for the accuracy of the information contained on the destination server, but offers this further information as a service to our visitors.
Funding Application (For Kansas Residents Only)
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5111 East 21st Street
Wichita, KS 67208
UCP of Kansas
Application for Financial AssistanceClient’s Name_____________________________Age________Birthdate__________
Address________________________________________________________________
City______________County_____________State____Zip________Phone(___)__________
Parent’s Name(s) (if client is a minor)____________________________________________
Father’s Place of Employment__________________________________________________
Mother’s Place of Employment_________________________________________________
Client’s Place of Employment__________________________________________________
Disability or Diagnosis________________________________________________________
Date of onset of disability (at birth)_____________________(other)____________________
Equipment requested__________________________________________________________
Total Cost $______________Amount family can contribute toward cost _____________
Amount requested from UCP $________________
Have other agencies or groups been contacted for assistance?
Yes_____ No_____
If Yes, which agencies and what were the results?Will your personal insurance cover any or all of the equipment requested?
Yes_____ No_____
If Yes, how much?__________________________________________Name of Insurance Company_____________________________________________
Is client eligible for and/or receiving assistance from: (circle one) Health Wave Yes No Social Security Yes No Supplemental Security Income (SSI or SSDI Yes No Kansas Special Health Services Yes No Medicaid Yes No Medicare Yes No
Do you have a prescription or professional recommendation for the item requested?
Yes_____ No_____
If Yes, from whom? _______________________________Gross annual family income $_________
# of persons living in the household _____I verify that the information provided above is accurate and agree to complete a follow-up questionnaire if provided with financial assistance.
------------------------------------------------------------------Signed__________________________________________
Dated___________________________________________
Please return completed form to:
UCP of Kansas P.O. Box 8217 Wichita, KS 67208
URL: http://www.ucpkansas.org
Updated: 05/16/2006
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