Apply For Help

If you or someone you know is living with a severe physical disabilitity and needs our assistance please fill out the following form:

Name (required): *
Address:
Email (required): **.
Primary Phone # (required) **
Has KOKO assited you in the past? (required) *
What is your medical condition?

Briefly describe what type of help you are seeking, including estimated costs
(required, please keep request to 350 words or less)

 *
 

 

Please note the following:

1)Requests MUST be for assistance that complies with our stated mission statement (i.e.-assisting those living with severe physical disabilities such as Cerebral Palsy and Muscular Dystrophy.)

2) Our current case limit is a maximum of $10,000. Smaller requests have the greatest chance of winning approval.

3) You may still apply if we have assisted you in the past, however first time applicants/cases will receive priority

4) Our case focus is currently the Greater-Chicago area. You may still apply if you are not currently in this area, however please understand chances of approval are slight and depend on need and available resources on our end. We will still try to put you in contact with someone who can help you should we not be able to approve your case.

5) Expect an initial response in 1-3 days. However final approval may take up to 1-3 months.