2025 Program Payment Form

All Clients:

Please complete the following information so we can update our client records.
We maintain client confidentiality for all information. Thank you.

Name:

Street Address:

Mailing Address if different from Street Address:

County of residence: (For example: Pitkin County/Eagle County/Garfield County)

County of work:

Contact Phone:

Email Address:

Date of Birth:

US Citizen:

Yes

Driver’s License ID:

OR Other Government Issued ID:

Annual Client Program Fee Payment

The value of program services rendered to you is $500.00 and you are not entitled to claim a charitable contribution deduction for this amount. Scholarships are available upon request.

I have enclosed a check for $500 for my annual program fee.

Please charge my credit card $500 to cover the cost of my annual program fee.

Please charge my credit card a monthly fee (to be determined per individual) until my $500 annual program fee has been met. We will call you to verify details.

Name:

Billing Address:

Zip Code:

Please complete the form first, and then call us to provide the card details.

Credit Card

Visa:

Mastercard:

Discover:

CC #:

Expiration Date:

Security Code:

* All clients are required to complete a current waiver and update the Client Information Form and Medical Release if necessary.

If you are currently a client for the Bridging Bionics Foundation (BBF) program and you have had a change in your health condition or if you have a change in medications, please provide an update here:

Healthcare

The following information is helpful for us to know, as the BBF program is a charitably funded initiative. We recognize that Medicare/Medicaid and some insurance companies currently do not reimburse for Galileo Training Systems or exoskeleton therapy

Do you have health insurance?

Yes

Name of Insurance:

Policy type:

Do you have Medicare/Medicaid?

Yes

Medicare is a federal program that provides health coverage if you are 65 or older or have a severe disability, no matter your income.
Medicaid is a state and federal program that provides health coverage if you have a very low income.

If you are eligible for both Medicare and Medicaid (dual eligibility), you can have both.

Name of person filling out application:

Relationship to Applicant:

Signature: Clear

Date:

BRIDGING BIONICS FOUNDATION is an IRS designated 501(c)(3) Public Charity: EIN# 46-2182977

PO Box 3766, Basalt, CO 81621 – USA