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CSN Fund Application

family with 2 children

CSN Fund Application

red adaptive tricycle

Rifton Tricycle form

Small or Medium tricycle

Large tricycle

What's Needed for an Application?

  • CSN Fund Application (Form DCH-1239)
  • Letter from the family explaining the need and reason for the request
  • Letter of medical necessity from the child's specialist explaining the need for the requested item
  • Documentation of Assistance (Form DCH-2423)
  • Bids/quotes for the item (see table on page 2 of the application)

Additional Required Items (if applicable)

  • Financial Assessment (Form DCH-1273) ~ ONLY if the child is not enrolled in CSHCS
  • Landlord Agreement (Form DCH-2424) ~ ONLY for wheelchair ramp or electrical upgrade on rental property
  • Rifton (or AMTRYKE) order form (small/medium OR large) completed by OT/PT ~ ONLY if requesting a Rifton or AMTRYKE