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Apply for Assistance

Note: due to high demand and current funding limitations, all completed applications will be added to our waiting list. Your application is considered complete after you submit the application below and we receive your diagnosis verification. We do recommend you apply. Once funding becomes available, we will process applications in the order in which they are completed.

Read these instructions carefully before you apply

If you or a loved one have been diagnosed with Parkinson's Disease, you are a US citizen / permanent resident whose primary residence is in the state of Florida, you may apply for financial assistance from us. To do so, fill out our application form as completely as possible. You can submit the form right here online, or you can download the form (click here to view and download the pdf), fill it out, and email it to us.

If you are submitting online, we suggest you first review the form to see what information is asked, gather that information, and then come back here to complete the form. You will need to provide:

  • Personal contact information.

  • The name, practice name, and address for your neurologist / movement disorder specialist and your primary care physician.

  • When you were diagnosed (month and year) and your age at diagnosis. 

  • Financial information: annual income from your latest tax return, estimated net worth, estimated monthly expenses. 

  • A short description of what you are asking for help with and why. 

The application may be completed by someone else, such as a care giver or family member, on behalf of the person with Parkinson's, as long as they have been authorized to provide the required information.

Once your application has been submitted, you will receive an email containing our diagnosis verification form. Give that form to your diagnosing neurologist and ask them to complete it and return it to us. Your application is not considered complete until we receive that verification.

We value your privacy, and we treat your information as strictly confidential.

If you have any questions, you may contact us at [email protected].