Please send completed application, along with the following documents to [email protected]:

1. A letter of medical necessity (LMN) from your therapist detailing the requested adaptive/medical equipment (please include the name of the equipment, brand, accessories, and attachments);
2. A detailed quote from your equipment vendor for the adaptive/medical equipment requested (please note that unlocked, Inc. will utilize its own equipment vendors for grant purchases);
3. Letter of denial from your insurance company for the requested adaptive/medical equipment or a letter from your insurance company detailing the amount covered for the requested adaptive/medical equipment; and
4. A letter explaining your child’s story. Please include as much information as you are willing to share about your child, his/her condition, your family, the reason your child needs the requested equipment and the impact or benefit you hope to achieve from the requested equipment. Application (002)