First, what's your name?
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If you're filling this out for someone else, please enter their name in this section. Thanks!
First Name
Last Name
Nice to meet you!
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We are so glad you signed up for our Wellness Challenge this round and are excited to support you in managing your lymphedema. At Ninjas Fighting Lymphedema Foundation, we love getting to know each and everyone in the lymphedema community.
So tell us a little about yourself and why you joined this program!
We're so excited to work with you!
Lymphedema affects everyone differently, both physically and emotionally. If you're open to sharing, could you tell us some of the areas of your life that are more challenging because of lymphedema right now? Are there any hobbies or activities that lymphedema is keeping you from enjoying?
No matter where you are in managing your lymphedema, we want to support you in finding or getting back to the things you love to do!
Thanks for sharing all of that!
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Now you might have already told us where your lymphedema is, but for our application process to work it's best, we need you to go ahead and check off all the regions you have swelling in so we can make sure we didn't miss anything!
Now that we have that information...
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What kind of compress garments or supplies can Ninjas support you with? Select all that apply.
(Please note that while our goal is to help everyone get exactly what they need, selecting the garments and supplies below does not automatically guarantee approval for any or all products. Thanks for your understanding!)
Okay, got it!
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For your safety and in order to help you get exactly what you need for your lymphedema, we require everyone we support to be under the care of a lymphedema therapist. Are you currently working with one?
If you are currently working with a therapist or graduated therapy within the last 30 days, please tell us how to get in touch with your therapist here:
Include the first and last name of your therapist, their facility or clinic name, their phone number, and email address if possible. Not all therapists share their email addresses, so we understand if you can only give us their phone number right now!
Now that we know all about you and your lymphedema, we do need to ask some questions about your financial situation based on the rules and regulations of our non-profit organization.
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Your insurance and income information do not immediately qualify or disqualify you for support from Ninjas Fighting Lymphedema Foundation, so please answer as best you can so we can make sure we have all the information we need to consider your application as a whole! We understand that caring for lymphedema (and any other health issues you or your family may be dealing with) can be expensive no matter what your financial situation looks like on paper!
Why are you seeking financial assistance from Ninjas Fighting Lymphedema Foundation?
Email
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Phone
If you are within the United States
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Phone
If you are outside the United States
Country
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Address
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Where we can send packages securely should your application and supplies be approved!
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
