The Matty Eappen Foundation Equipment Reimbursement Fund:

...............Application for Surviving Victims of Shaken Baby Syndrome........................................

Full Name of SBS Survivor________________________________________________________________________
Date of Birth________________ Age________________________________________________________________
Names of Parent(s)/Guardian(s)_____________________________________________________________________
Home Address__________________________________________________________________________________
Home Phone___________________________________________________________________________________
E-Mail Address_________________________________________________________________________________

Date of Injury___________________________________________________________________________________
Medical Outcome________________________________________________________________________________
Physician caring for Patient_________________________________________________________________________
Physician’s phone number__________________________________________________________________________
Physician’s address_______________________________________________________________________________
Perpetrator/relationship____________________________________________________________________________

Equipment Being Requested________________________________________________________________________
Total cost of Equipment___________________________________________________________________________
Amount of insurance reimbursement expected___________________________________________________________
Amount of other outside funding expected______________________________________________________________
Therapist or Physician assisting with Equipment order (Name/Ph#)

__________________________________________________________________________________
Company equipment will be ordered from __________________________________________________
Company’s Website and/or phone #______________________________________________________
Item number and price of piece of equipment_________________
_____________________________________________________
(please include photocopy of equipment order and copy of MD prescription for equipment)

Please explain how this equipment will assist you in acquiring a better quality of life.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________

How many years do you expect to use this equipment?__________

I understand this fund is for Surviving Victims of Shaken Baby Syndrome. I give consent to the Matty Eappen Foundation to post portions of this application, including photo, on their web page or on other print materials. (Last names will not be used)

X_________________________________ Date_____________

Mail Application to:
Paula Passi McCue, PT
One Millbrook Rd
Natick, MA 01760

Visit our Website at www.mattyeappen.org

We gratefully acknowledge the Garth Brooks Teammates for Kids Foundation for the grant that seeds this Equipment Reimbursement Fund.