COVID-19 PPE Package Request Form

 

Please fill out the form below to request a Cure SMA COVID-19 Personal Protective Equipment (PPE) Package. Upon submitting the request form below, we will ship out your package in the order it was received and as supplies last. Please email covidPPE@curesma.org with any questions. Also, please note, we are unable to ship to P.O. boxes.

Eligibility Criteria:

  • Package is provided to individuals with spinal muscular atrophy (SMA) or a legal guardian of an individual with SMA.
  • You must have a confirmed diagnosis of SMA.
  • Must live within the United States.
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2. Applicant's Contact & Shipping Information:

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Question - Required - Affected Individuals Birthdate:




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Question - Required - Affected Individuals Diagnosis Date:




 

As part of the application for this support program, below are a few questions regarding how you or your family have been affected by the current global pandemic. This is part of Cure SMA's efforts to stay current with the impact COVID-19 is having on the SMA community so we can best meet your support needs. Completion of these questions is required.

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Question - Required - Has your child (or you if affected with SMA) had any of the following? (Check all that apply.)

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Question - Required - Has your child (or you if affected with SMA) experienced any of the following due to COVID-19? (Check all that apply.)

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Question - Required - Please check all that apply to you:

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