Application Materials

A foundation representative will be in contact after the information provided is reviewed.

Meanwhile, please review the application documents below. Additional instructions regarding the application process will be given at the time of contact. Thank you.

Agreement and Financial Application

Authorization of Disclosure

Insurance Information

Introductory Questions













Featured Testimonial

"With the Kees Brenninkmeyer Foundation, I benefitted more than I can explain. From the help of Kees Brenninkmeyer Foundation and Dr. Hackett’s team, I was able to recover better than I thought. With the help of Kees I was able to attend all P.T. appointments till the end of my recovery without the stress of the cost from back to back surgeries. After going through a big test of patience and strength I found myself supported by so many including Kees Brenninkmeyer Foundation. I cannot thank them enough for all they have done for me."

- Miranda Hicks

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