Piece of Mind Grant Application

Demographic Information

Name of child with ASD

First Last

Parent/Caregiver Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Refers to person with ASD

Age

Please enter a number from 0 to 90.

Refers to person with ASD

Sex

Male
Female

Refers to person with ASD

Email

Person completing application

Phone - Mobile

Person completing application

Phone - Home

Person completing application

Preferred Method of Contact

Email
Phone
Mail

Mark only one

List of all other household members and ages

Financial Need Section

Information supplied in this section will help determine financial need assistance.

Please list and briefly explain all sources of financial support the beneficiary is currently receiving for disability related servies. For example: Insurance, TEFRA, DDSD, Waivers, LEA (School services) or other grants or financial assistance.

Household Monthly Income - Please include ALL sources of income.

Does your child wander?

Do you have a smoke detector?

Is water safety a concern? Do you live near a pool or body of water?

Do you need home safety equipment?/Explain

Please tell us more about your situation and how the grant monies will provide you or your family memberrs with a safe home and community environment. Please include all financial, personal or extenuating circumstances that affect your family and your child/children.

Product Requested

Please use this section to provide specific information to the products or services that are being requested.

Provider Contact Information (if applicable)

Service or Equipment

Provider or Company Name (if applicable)

Estimated Cost of Service

What's Next

Applicants will receive a letter or email stating if they have been selected as a finalist. At that point, the applicant will asked to provide 1. First page of current signed Federal Tax Form 1040 2. Documentation of the disability from the doctor other qualified health professional 3. HIPPA Release form. PLEASE DO NOT PROVIDE THIS INFORMATION UNLESS ASKED. Grant applications and documentation will not be returned to the applicant.

If you are selected as a finalist, you will be asked to provide documentation of the disability. Please describe this documentation ONLY. For example, who provided the diagnosis, occupation of evaluator (medical Dr, Pyschologist, other); date of diagnosis.

If you are selected as a finalist, are you willing to provide the first and last page of your most recent tax return?