Prosthetics for Progress

Become a Beneficiary

Are you living with limb loss and facing financial hardship? You may qualify for a free prosthesis through the Transforming Lives: CEDE Prosthesis for Progress initiative.

Please fill out the form to confirm your eligibility. It only takes a few minutes, and your information is kept confidential.

First Name

Surname

Phone Number

Email Address (if any)

Date of Birth

Age

Gender

Marital Status

State of Origin

Current State of Residence

Residential Address

Occupation

Highest Level of Education Completed

If "Others", please specify

Date of Amputation

Cause of Amputation

If "Others", state other cause of amputation

Type of Amputation

If "Others", state other type of amputation

Which limb(s) is/are affected? (hold Cmd/Ctrl while clicking to select more than one)

Do you currently use any form of prosthesis?

Do you experience any of the following health conditions? (hold Cmd/Ctrl while clicking to select more than one)

Please specify health condition

Are you currently on any medications? If yes, please specify.

Have you ever received support from any organization for prosthetics or disability-related assistance?

Please provide details (name of organization, type of support received, date)

What challenges do you currently face due to your amputation?

Do you consent to CEDE using your story or image for awareness and advocacy purposes (with dignity and privacy respected)?

Why do you want to benefit from the Prostheses for Progress Initiative?

How did you hear about this initiative?

Please specify how you heard about this initiative

Do you have access to transportation for hospital visits or fitting appointments?

Any other information you'd like us to know?

Declaration

I hereby declare that the information provided is true and correct to the best of my knowledge. I understand that CEDE reserves the right to verify all information provided.

Become a Beneficiary

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