Walk - Giving Mobility, Changing Lives

Request Help

If you or someone you know needs a prosthetic device but cannot afford it, please fill out this form. We will review your request and may be able to help raise funds for your prosthetic device.

Full Name *

Email Address *

Phone Number

Age

Location/City *

Photo of Limb(s) *

Please upload a clear photo showing the current state of your limb(s). This helps us understand your specific needs. Maximum file size: 5MB. Accepted formats: JPG, PNG, GIF.

Your Story *

Security Question *

Please answer this question to verify you are human:

What is 5 + 3?

By submitting this request, you agree to our Privacy Notice and Terms of Use.

What happens next?

We review your request within 48 hours
If approved, we create a fundraising campaign
We contact you to discuss next steps

Your story will be shared with potential donors
We handle all fundraising logistics
You'll receive updates on progress