Lawyers Autism Awareness Foundation Treatment Grant Notice
|
|
- Jemima McCormick
- 8 years ago
- Views:
Transcription
1 Lawyers Autism Awareness Foundation Treatment Grant Notice ( LAAF ) is a nonprofit 501(c)(3) corporation whose mission is to foster autism spectrum awareness in the Tampa Bay area and raise funds to give needs-based grants to local families with children on the autism spectrum for approved autism therapy. LAAF is proud to offer a grant program for approved therapies, namely: Applied Behavior Analysis (ABA), Occupational Therapy, Physical Therapy or Speech Therapy; that may not otherwise be covered privately or by other third-party funding sources such as school districts, government programs, insurance or other grant making entities. Applicants with a primary diagnosis of an autism spectrum disorder, who meet the following grant program criteria and complete the Grant Application will be considered for LAAF treatment grants. Since, in most cases, the applicant s parent or guardian will be completing the application, it is understood that the applicant will be the individual receiving the benefits of the grants. Grant payments will be made directly to preapproved treatment providers. Parental/Family Involvement Parents and family members are central to helping children with autism spectrum disorders achieve their full potential. Family and parental commitment and involvement in a child s treatment is critical to the success of any treatment program. Therefore, LAAF will consider the child s family s dedication and involvement in their child s treatment as an important factor in awarding grants for treatment. Letters of recommendation from Doctors, Therapists or Teachers may be submitted with the application and will be considered by the Grants Committee. Grant Amounts and Selection of Recipients Grants of up to 5, per family will be allocated based on annual fundraising activities and the needs of the grant applicant. Recipients will be evaluated and ranked by an independent grant selection committee. The Board of Directors will determine the number and amounts of each grant. Grant recipients must reside in the Tampa Bay area (Hillsborough, Pinellas, Pasco, Polk and Hernando counties). LAAF board and grant committee selection members and their families are not eligible for treatment grants.
2 Applicants must demonstrate financial need by providing the following: Proof of Household Income (including, but not limited to; tax returns, paystubs, proof of assets, SSI statements. Number of Dependants & Number of Dependants with Autism Spectrum Disorders. Information about access to third-party funding sources. Including, but not limited to, other grants, government programs, insurance or the like. The following must be sent to LAAF in order to be eligible for grants: Completed, signed and dated Grant Application. Verification of Diagnosis (please provide documentation as proof of diagnosis). Documentation from therapy provider of your requests (pg. 7) stating costs of the requested treatment. Brief Description of current family situation. Copy of Previous Years Tax Return. Provider Certification Grants to be paid periodically to approved providers. LAAF reserves the right to require documentation from the child s provider, including documentation of progress, continuing need for therapy and parental/familial involvement in the child s prescribed treatment. Grant Applications must be postmarked no later than the deadline date specified. No ed Grant Applications will be accepted Should your grant be funded, it is the applicant s responsibility to provide LAAF with the treatment provider s contact information no later than 45 days and commence treatment within 60 days after the notice of grant approval has been made. The funds should be used within 12 months of the commencement of treatment. Otherwise, LAAF reserves the right to rescind the offered grant and award the funds to another candidate. You will be asked to complete two short questionnaires regarding your experiences as a result of the funding you received. We also encourage families to share photos and stories.
3 Grant Applications must be mailed to: LAAF Attn: Grant Committee P.O. Box Tampa, FL Any Applicant receiving a grant agrees to repay the grant if any services paid for with the grant are reimbursed by another funding source, such as, a school district or insurance company. The grant deadline is posted below. Incomplete Grant Applications will not be considered. Applications must be postmarked by June 30 th, 2014 Recipients will be announced by September 1 st, Please direct any questions to: info@thelaaf.org. However, please note that applications will not be accepted via . Applications must be submitted via U.S. Mail and postmarked by the date above.
4 LAAF - Grant Application Please type or print clearly in the form below Today s Date: How did you hear about LAAF s Grant Program? General Information Applicant s Name (Child affected by Autism Spectrum): Applicant s Date of Birth: Applicant s Current Age: Street Address: Applicant s Gender: Male Female City: State: Zip Code: 1) Guardian #1 Name: Relationship: Home Telephone Number: Work Telephone Number: Cell Number: Address: 2) Guardian #2 Name: Relationship: Home Telephone Number: Work Telephone Number: Cell Number: Address:
5 Dependant/Sibling Information Autism Spectrum Diagnosis Name: Age: Relation to Applicant: Yes No Name: Age: Relation to Applicant: Yes No Name: Age: Relation to Applicant: Yes No Name: Age: Relation to Applicant: Yes No Name: Age: Relation to Applicant: Yes No History Consent: This form authorizes the use and/or release of the protected health information as noted below for purposes of the LAAF grant review process. I give LAAF permission to verify treatment information by contacting the treatment vendors directly. This authorization shall be valid for one year unless otherwise stated. I understand that I may revoke this authorization in writing at any time. Signature/Date: Current Diagnosis: Date of Diagnosis: Diagnosed by: (Name of Physician or Qualified Provider) Name of Institution where Diagnosed: Telephone Number: Street Address: City: State: Zip Code:
6 Current and Previous Treatment Type of Treatment Treatment History (check one) Frequency (hours/week) Provider of Services Speech Therapy Occupational Therapy Physical Therapy Applied Behavior Analysis Special Diets, Biomedical Testing and Intervention Social Skills Groups Medication Management (please list medications) Other: (please explain) Other: (please explain) Please describe the child s parental/family involvement in the foregoing treatment program(s), including the amount of time parents/guardians are involved in therapy programs or at-home therapy regimens (attach an additional sheet, if needed):
7 Grant Funds Request Please complete requested information and include copies of supportive documentation, such as letters of support from service providers, service/intervention descriptions, treatment cost sheets, provider brochures, receipts, etc. Supportive documentation must include cost of treatment/items. Direct Treatment Total Cost of Treatment: Grant Amount Requested for Treatment: Supportive Documentation Attached: Yes No (If No application will not be considered) Grant Request is for the following Service(s)/Therapy(ies) (check each you are requesting): Speech Therapy Occupational Therapy Applied Behavior Analysis Therapy (ABA) Provider Name: Provider Telephone Number: Street Address: City: State: Zip Code: Describe details: (Include who will provide treatment, frequency and duration of treatment, etc.) Financial Information Guardian #1 Current Monthly Gross Income: Guardian #2 Current Monthly Gross Income: Other Sources of Income (Name of Source): Please attach copy of previous year s Tax Return Please attach copy of previous year s Tax Return
8 Funding Sources (including other grants or scholarship awards) Check all funding sources that apply and complete the requested information. Private/Health Insurance Insurance Company: Contact Person: Telephone Number: Treatments Covered: Treatments not Covered: Total Amount covered (annually) Total Amount not covered (annually) Medicaid /Other State Program Program name: Contact Person: Telephone Number: Treatments Covered: Treatments not Covered: Total Amount covered (yearly) Total Amount not covered (yearly) School District Name of District: Contact Person: Telephone Number: Treatments Covered:
9 Funding Sources (continued) Other Describe: Contact Person: Telephone Number: Treatments Covered: Other Describe: Contact Person: Telephone Number: Treatments Covered: Other Describe: Contact Person: Telephone Number: Treatments Covered:
10 Description of Family Situation Please briefly describe in the space provided below your family situation. Please do not attach a separate sheet. Letters of Recommendation (optional). Please attach no more than two letters of recommendation from service providers, case workers or other individuals familiar with your family s situation. Letters of recommendation are optional and should be no more than one page in length.
11 FOR LAAF OFFICE USE ONLY Application Postmarked by Deadline YES NO Diagnosis Verification YES NO Treatment Verification YES NO Support Documents to Verify Costs Assessment Verification YES NO Copy of Previous Year s Tax Return Submitted YES NO Brief Description of Situation Submitted YES NO LAAF GRANT SELECTION COMMITTEE Application Rank Comments: _ Approved LAAF Board Declined Reason: _ Amount Approved (Up to 5,000.00): Authorized Provider Name: Date Applicant Notified: Board Approval by: Signature: Date:
12 RELEASE AND AUTHORIZATION FOR USE OF IMAGE I hereby release LAAF to use photographs, reproductions, video tapes, recordings or endorsements of/by me and/or my child for publicity, fundraising or any other purpose. Name of Parent: Description of Use: I hereby grant LAAF the following rights: 1. To use my / my child s first name (you may ask that names are withheld see below), photograph, picture, portrait, likeness, and voice in connection with its educational materials or publicity or for any other legitimate reason. 2. To use, reproduce, publish, exhibit, distribute, and transmit my/my child s image individually or in conjunction with other images or printed matter in the production of brochures, motion pictures, television tape, sound recordings, still photography, CD-ROM, and other media. 3. To record, reproduce and amplify my image. I hereby release and discharge LAAF, including but not limited to its Board members, officers, committee members, volunteers and agents, from any and all claims, actions and demands arising out of or in connection with the use of said image, including, without limitation, any and all claims for invasion of privacy and libel. I hereby waive the right to inspect or approve my/my child s image or any finished materials that incorporate my image. I understand and agree that I will receive no compensation, now or in the future, in connection with the use of my / my child s image. I represent that I have read the preceding and completely understand the contents. Authorizer s Name & Relationship to Child: Child s Name: Signature of Parent or Guardian: Date: Authorized Use of Name (please check one): Yes No
Spokane Kiwanis Charities Foundation Scholarship
Spokane Kiwanis Charities Foundation Scholarship PO Box 4961 Spokane, WA 99220 kiwanisdtspokane.org HIGH SCHOOL SCHOLARSHIP APPLICATION INSTRUCTION FORM Community Service Scholarship Spokane Kiwanis Charities
More informationBe An Angel Fund, Inc. 2003 Aldine Bender Houston, Texas 77032 or Fax to : 281-219-7746 or Scan and email to : russ@beanangel.org
Page 1 of 9 It is our MISSION to improve the quality of life for children with multiple disabilities or profound deafness by providing adaptive equipment and select services to individuals and institutions
More informationTampa Chapter The Links, Incorporated Scholarship Program
Tampa Chapter The Links, Incorporated Scholarship Program 2014-2015 Tampa Chapter The Links, Incorporated Scholarship Application Tampa Chapter of The Links, Incorporated is a volunteer service organization
More informationCollege Scholarship Competition Announcement 2014. Dear Teachers, Guidance Counselors, Parents and Students:
MOUNT MORRIS PARK COMMUNITY IMPROVEMENT ASSOCIATION PO Box 3270, New York, NY 10027 info@mmpcia.org mmpcia.org 212.369.4241 College Scholarship Competition Announcement 2014 Dear Teachers, Guidance Counselors,
More informationWhite Rose Scholarship Foundation
White Rose Scholarship Foundation Dear Applicant: We are pleased you have chosen to apply for a 2016 White Rose Scholarship. White Rose is an outreach program of the Rocky Mountain Court System and the
More informationPhysical, Occupational, Speech & Developmental Therapy
Physical, Occupational, Speech & Developmental Therapy Let me begin by saying thank you for choosing Allied Therapy and Consulting Services as your child s therapy provider. We hope to make this a smooth
More informationRULES FOR FILING A CLAIM AND APPEAL RIGHTS
DIVISION OF TEMPORARY DISABILITY INSURANCE APPLICATION FOR FAMILY LEAVE INSURANCE BENEFITS (FL-1) DETACH THIS PAGE AND KEEP FOR YOUR RECORDS RULES FOR FILING A CLAIM AND APPEAL RIGHTS 1. It is your responsibility
More informationDear Parents: We appreciate the opportunity to work with your child and look forward to getting to know your family. Sincerely,
Dear Parents: Thank you for considering Mobile Therapy Centers of America, LLC (MTC) for your child s therapy needs. At MTC, we strive to provide the highest quality of therapeutic intervention. Our services
More information2016 SCHOLARSHIP AWARDS
2016 SCHOLARSHIP AWARDS Scholarships have been awarded in the range of $500- $2,000. The exact amount will be determined each year and will be dependent on the annual earnings from designated Foundation
More informationBuffalo Soldiers Motorcycle Club Miami Florida, Inc. 2012 Barry Jennings College Scholarship Application
Buffalo Soldiers Motorcycle Club Application Deadline March 30, 2012 2012 Barry Jennings College Scholarship Application Point of contact for additional questions or information: Maasia Green Scholarship
More informationMost Frequently Asked Questions about Applied Behavior Analysis Services for the Treatment of Children under 21 with Autism Spectrum Disorders
Most Frequently Asked Questions about Applied Behavior Analysis Services for the Treatment of Children under 21 with Autism Spectrum Disorders Common Abbreviations ABA Applied Behavior Analysis AHCA The
More informationCENTRAL FLORIDA GATOR CLUB SCHOLARSHIP APPLICATION UNIVERSITY OF FLORIDA 2014 APPLICATION YEAR
CENTRAL FLORIDA GATOR CLUB SCHOLARSHIP APPLICATION UNIVERSITY OF FLORIDA 2014 APPLICATION YEAR Congratulations on your acceptance to THE University of Florida! Central Florida Gator Club PO Box 941987
More information2015 CENTRAL FLORIDA GATOR CLUB SCHOLARSHIP APPLICATION UNIVERSITY OF FLORIDA
2015 CENTRAL FLORIDA GATOR CLUB SCHOLARSHIP APPLICATION UNIVERSITY OF FLORIDA Congratulations on your acceptance to THE University of Florida! The Central Florida Gator Club, an affiliate organization
More informationDymond Speech & Rehab., P.A. Patient Registration Information
Dymond Speech & Rehab., P.A. Patient Registration Information Client s Name: First Middle Last Street Address: Mailing Address: City : State: Zip code: Sex: Home Phone: ( ) - Cell: ( ) - Other: ( ) - of
More informationPolicies for Easter Seals South Carolina Therapy Services
Policies for Easter Seals South Carolina Therapy Services It is our goal to serve you and your child with excellence. Please carefully read through the following policies. 1. During or prior to your initial
More informationAPPLICATION CHECK LIST
APPLICATION CHECK LIST Full application includes: o Patient Information Form o Household & Family Financial Profiles o Employment/Salary Verification. This form must be signed by the employer o Methodist
More informationMBA Opens Doors Foundation SM Mortgage Assistance Grant Application
MBA Opens Doors Foundation SM Mortgage Assistance Grant Application MBA Opens Doors Foundation sm provides assistance to homeowners with critically or chronically ill or seriously injured children by making
More informationOU-Research Experience for Teachers (OU-RET) At the University of Oklahoma
OU-Research Experience for Teachers (OU-RET) At the University of Oklahoma Please print clearly or type APPLICATION FOR Summer 2011 (deadline May 2, 2011) Legal Name Last First Middle Maiden Name or other
More informationScholarship Application
Scholarship Application About Us The Epicurean Charitable Foundation Las Vegas (ECF) is a nonprofit organization dedicated to the enrichment, involvement and education of those individuals committed to
More informationGreenStone Farm Credit Services 2015 Scholarship Program
GreenStone Farm Credit Services 2015 Scholarship Program GreenStone Farm Credit Services will award up to $40,000 in scholarships to incoming college freshman in the amount of $2,000 each to selected students
More informationOCI Foundation Scholarship Application
OCI Foundation Scholarship Application Dear Applicant: In order to be considered for the Orthopedic Center of Illinois Foundation Scholarship, the following application must be completed in its entirety.
More informationBuilding a Healthier Sulphur Springs 2015 Application Package
Building a Healthier Sulphur Springs 2015 Application Package Dear Applicant: Thank you for your interest in Rebuilding Together Tampa Bay s Building a Healthier Sulphur Springs Program. Rebuilding Together
More informationREGISTRATION AUTISM TREATMENT SERVICES
559 Zor Shrine Place Madison, WI 53719 P: 608.833.0123 F: 608.833.0126 www.ids -wi.com CLIENT INFORMATION (First, MI, Last) (Street, City, State, Zip) REGISTRATION AUTISM TREATMENT SERVICES of Birth Home
More informationGHRA HOSPITALITY & CULINARY ARTS SCHOLARSHIP Deadline: March 25, 2011
Application Guidelines and Instructions Completed scholarship application must be postmarked by March 25, 2011, unless otherwise specified. Selection of GHRA Houston Community College Scholarship is based
More informationBAGSF Mission. BAGSF Scholarships: (All applicants must apply using the most current year s scholarship application.)
BAGSF Mission Bay Area Gardener s Scholarship Foundation strives to promote the educational attainment achievement of all diverse students in the Bay Area by among other things, conducting public discussions,
More informationISRI Northern Ohio Chapter. Recycling Research Foundation. 2015 Scholarship Application
ISRI Northern Ohio Chapter Recycling Research Foundation 2015 Scholarship Application Bill Ivancic Scholarship Committee Chairman Bluestar Metal Recycling 440-323- 3950 bill@bluestarmetal.com Conserving
More informationMontefiore s Health Opportunities Program (Monte-HOP) Summer Internship Program Application Deadline: April 17, 2015
Montefiore s Health Opportunities Program (Monte-HOP) Summer Internship Program Application Deadline: April 17, 2015 Please read application package in its entirety. Program Description: The Montefiore
More informationRESOURCE MEMO #HE17 Date: July 30, 2008 RE: Free Dental Care Application
United Cerebral Palsy Association of Greater Indiana, Inc. 107 N. Pennsylvania St., Suite 804 Indianapolis IN 46204 800-723-7620 Fax 317-632-3338 http://www.ucpaindy.org RESOURCE MEMO #HE17 July 30, 2008
More informationThursday, July 9th, 2015 and Friday, July 10th, 2015 from 7:30 AM to 5 PM
Dear Applicant to Nurse Academy and Parent/Guardian, Thank you for your interest in Nurse Academy 2015. Nurse Academy is designed for the student who is interested in exploring the profession of nursing
More informationPRE-SCREENING CHECKLIST
PRE-SCREENING CHECKLIST Please provide the following information and mail, email or fax to: Positive Synergy Corp. 45 Spring Hill Ave. Northbridge, MA 01534 Email: intake@positivesynergyasd.org Fax: (508)-401-2696
More informationScholarship Application
Scholarship Application About Us The Epicurean Charitable Foundation Las Vegas is a nonprofit organization dedicated to the enrichment, involvement and education of those individuals committed to pursing
More informationApplication for Services Checklist
Application for Services Checklist This form is not required, but rather is meant to help families gather all required information and documentation required to start ABA services at Behavior Analysts
More informationThe Marianna Taylor Memorial Scholarship Scholarship
Scholarship ~~~ Marianna Taylor Bio ~~~ Marianna Taylor was one of the most generous and loving people you will ever meet. Mari was an active Fort Worth community member for many years. People remember
More informationBaylor Autism Resource Center Applied Behavior Analysis (ABA) Therapy Program
Baylor Autism Resource Center Applied Behavior Analysis (ABA) Therapy Program Please see the enclosed information and application for more information. The Baylor Autism Resource Center (BARC) Applied
More informationDymond Speech & Rehab., P.A. Patient Registration Information
Dymond Speech & Rehab., P.A. Patient Registration Information Client s Name: First Middle Last Street Address: Mailing Address: City : State: Zip code: Sex: Marital Status: Home Phone: ( ) - Cell: ( )
More informationHow To Write An Early Intervention Program Record Book
New York State Department of Health Early Intervention Program Responses to Technical Assistance Questions From Municipalities CPT Codes/ICD-9 Codes 1. Where/how can counties access a full and accurate
More information2016 Scholarship Program
Eligibility A. The entrant must be a Member of LBS Financial Credit Union and in good standing, prior to submitting a scholarship entry form. B. Student must be enrolled as a high school senior or at an
More informationPolicy Evaluation and Application Form
1507 Park Center Drive, Unit 1B Orlando, FL 32835 888-335-4769 Fax: 321-400-1084 www.assetlifesettlements.com Personal Data Policy Evaluation and Application Form First Insured Name: SS #: Current Address:
More informationDO I QUALIFY? To qualify for assistance from Ribbon Riders, you must meet the following criteria:
Ribbon Riders, Inc. PO Box 952283 Lake Mary, FL 32795 407.796.7465 Thank you for contacting Ribbon Riders regarding our Breast Cancer Assistance program. Please review the attached information prior to
More informationSCHOLARSHIP PROGRAM and APPLICATION
Tennessee Gas Association Scholarship Foundation SCHOLARSHIP PROGRAM and APPLICATION (COLLEGE/UNIVERSITY APPLICANTS) 83 CENTURY BOULEVARD NASHVILLE, TN 37214 (615) 872-2411 jwellman@tngas.org www.tngas.org
More informationScholarship application deadline: April 15, 2014
THE KIWANIS CLUB OF ABILENE FOUNDATION, INC. 473 CYPRESS ST., SUITE 107, ABILENE, TX 79601 (325) 673-1341 Building One Child and One Community at a Time Scholarship application deadline: April 15, 2014
More informationCharles Edward Cathey Masonic Scholarship
Guidelines & Application Charles Edward Cathey Masonic Scholarship 2016 The Grand Lodge of Ancient, Free & Accepted Masons of North Carolina www.grandlodge-nc.org The 2012 Charles Edward Cathey Masonic
More informationEnrollment Application 2014-2015
Enrollment Application 2014-2015 Student Name: Date: Current Grade Level: Current School: Date of College Track Presentation: Submit Application by: Checklist of items that must be returned to College
More informationJacob s Ladder Pediatric Rehabilitation Center, Inc. Child Respite Program
Page 1 of 5 Intake Sheet Child s Name #1 Age Birth Date Grade: School: Sex: M F Diagnosis/Disability: Child s Name #2 Age Birth Date Grade: School: Sex: M F Diagnosis/Disability: Father/Mother/Guardian:
More informationLOCAL 372 N.Y.C. BOARD OF EDUCATION EMPLOYEES SHAUN D. FRANCOIS I, PRESIDENT
LOCAL 372 N.Y.C. BOARD OF EDUCATION EMPLOYEES SHAUN D. FRANCOIS I, PRESIDENT SCHOLARSHIP APPLICATION 2016 2016 LOCAL 372 SCHOLARSHIP FUND REGULATIONS GOVERNING USE OF SCHOLARSHIPS Scholarship awards of
More informationRegion 14 - Hopewell Center Consultation/Evaluation Referral Packet For Children 3 to 22 Years Old
Region 14 - Hopewell Center Consultation/Evaluation Referral Packet For Children 3 to 22 Years Old Please use this packet to request the following Hopewell services: Motor Evaluation (Adapted Physical
More informationIndividuals wanting to purchase a car through this program must meet the following qualifications:
Tier II Program Individuals wanting to purchase a car through this program must meet the following qualifications: You must have a verifiable job offer or be working at least 30 hours a week. If enrolled
More informationIndiana Donor Network Foundation Scholarship/Care Council Members
Dear Applicant: Thank you for requesting an Indiana Donor Network Foundation scholarship information packet. Indiana Donor Network is the nonprofit health service dedicated to advancing organ, tissue and
More information2012-2013 ACADEMIC YEAR SCHOLARSHIP INFORMATION
Military Order of the Purple Heart 5413-B Backlick Road Springfield, Virginia 22151 Phone: (703) 642-5360 Fax: (703) 642-2054 or 1841 Email: scholarship@purpleheart.org 2012-2013 ACADEMIC YEAR SCHOLARSHIP
More informationCommunity Health Programs Patient Registration
Community Health Programs Patient Registration Last Name: First Name: Preferred name: Middle Initial: Suffix: Gender: Male Female Former Last Name: Date of Birth: / / Social Security Number: SSN: Mailing
More informationFALL 2009 HIGH SCHOOL STUDENTS SCHOLARSHIP APPLICATION
PRINCE GEORGE S COUNTY DELTA ALUMNAE FOUNDATION, INC. in association with DELTA SIGMA THETA SORORITY, INC. PRINCE GEORGE S COUNTY ALUMNAE CHAPTER FALL 2009 HIGH SCHOOL STUDENTS SCHOLARSHIP APPLICATION
More informationMaine Roads Scholarship Program Degree Information 2015-2016
www.muskie.usm.maine.edu/maineroads Maine Roads Scholarship Program Degree Information 2015-2016 PLEASE READ BEFORE COMPLETING APPLICATION FORM I. DEFINITION The Maine Roads Scholarship Program is a financial
More informationGoodman Fielder Income Protection Claim Form
Section A Claimant s Section Goodman Fielder Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The
More informationThere is no formal application process. However, for consistency, we have provided:
TO: FROM: NC Community Colleges Financial Aid Directors SECU Foundation DATE: January 5, 2016 RE: 2016 People Helping People Scholarship Enclosed is the 2016 SECU Foundation People Helping People Scholarship
More informationCLAIMANT RIGHTS AND RESPONSIBILITIES RULES FOR FILING A CLAIM AND APPEAL RIGHTS
DIVISION OF TEMPORARY DISABILITY INSURANCE CLAIM FOR DISABILITY BENEFITS (DS-1) DETACH THIS PAGE AND KEEP FOR YOUR RECORDS CLAIMANT RIGHTS AND RESPONSIBILITIES RULES FOR FILING A CLAIM AND APPEAL RIGHTS
More informationAPPLICATION FOR BENEFITS LAW ENFORCEMENT OFFICERS AND FIRE FIGHTERS DISABILITY BENEFITS TRUST FUND
EXHIBIT A M S Attorney General s Office Use Only: Application #: Receipt Date: G Approved G Disapproved Claim type: G Law Enforcement Officer G Fire Fighter STOP. Please read the fund policies and procedures
More informationLifetouch Orthopedic Physical Therapy. -- PLEASE PRINT -- Patient Information. Proper Name First Middle Last Name you use
Lifetouch Orthopedic Physical Therapy How did you find out about Lincoln Orthopedic Physical Therapy? Past patient/friend or family Physician Yellow Pages Web Site Location/Street sign Attorney/Nurse Case
More informationREGISTRATION FORM. How would you like to receive health information? Electronic Paper In Person. Daytime Phone Preferred.
Signature Preferred Pharmacy Referral Info Emergency Contact Guarantor Information Patient Information Name (Last, First, MI) REGISTRATION FORM Today's Date Street Address City State Zip Gender M F SSN
More information"Link to the Future Scholarships"
ATTENTION ATTENTION ATTENTION ******** High School Seniors "Link to the Future Scholarships" awarded by: North Broward County Chapter of The Links, Incorporated For Students Enrolling in College: (Community,
More informationMontgomery County Ohio College Promise
Montgomery County Ohio College Promise Montgomery County Ohio College Promise Scholarship Program Application Montgomery County Ohio College Promise applicants must: Be currently enrolled in school as
More information2014 Irvin Specht & Emily Argo Memorial Scholarship Application
Applications for college scholarships offered each year by the Cincinnati Police Federal Credit Union are due no later than March 28, 2014. The credit union offers two $4,000 scholarships each year to
More informationWhat to bring to your first appointment:
Tampa Bay Community Development Corporation Housing Counseling Services 2139 N.E. Coachman Road, Suite 1, Clearwater, FL 33765 Phone: (727) 442-7075 (866) 608-3220 (813) 849-1121 Fax: (727) 446-8727 www.tampabaycdc.org
More informationMidwest Dairy Association IOWA DIVISION EDUCATIONAL AWARD AND APPLICATION INFORMATION
Midwest Dairy Association IOWA DIVISION EDUCATIONAL AWARD AND APPLICATION INFORMATION To the Applicant: The Iowa Division of Midwest Dairy Association will be awarding 20 $1,000 educational awards. Applicants
More informationMaritime Super Income Protection Claim Form
Maritime Super Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all
More informationImportant Information Please keep this page for your records
Camp Horizon Important Information Please keep this page for your records 1. Complete the enclosed application and the scholarship form thoroughly. Mail them immediately to the camp address listed below.
More informationPRELIMINARY LIFE INSURANCE APPRAISAL REQUEST
PRELIMINARY LIFE INSURANCE APPRAISAL REQUEST INSURED INFORMATION (If more than one insured, please duplicate this page and complete for each insured.) Name SSN Current Address Date of Birth Day Telephone
More information$$$ PROJECT PRO$PER LOAN APPLICATION $$$
$$$ PROJECT PRO$PER LOAN APPLICATION $$$ Project Prosper s mission is to prepare recent working immigrants to participate fully in the economic life of the community through a program of small loans, matched
More informationApplication Letter of Instruction
STATE OF NEVADA BOARD OF OCCUPATIONAL THERAPY P.O. BOX 34779 Reno, Nevada 89533-4779 (775) 746-4101 / Fax: (775) 746-4105 / Toll Free: (800) 431-2659 Email: board@nvot.org / Website: www.nvot.org TYPES
More informationPhysical Therapy Services Medical History Form
Physical Therapy Services Medical History Form Last Name First Name DOB Age Diagnosis: Physician: Check Yes or No. If yes, please explain in the space provided. Yes No Are you pregnant? Yes No Currently
More information2015 FRA Education Scholarship Program LA FRA Scholarship Deadline: Postmarked No Later Than April 15, 2015
RULES 1. You may apply for LA FRA Member Scholarships if the applicant or sponsor is a member in good standing of the LA FRA or FRA, currently or at time of death. The applicant must be a LA FRA or FRA
More informationAuxiliary of Doctors Hospital
Auxiliary of Doctors Hospital Scholarship Committee Information 2016 1 Auxiliary of Doctors Hospital Scholarship Fund May 2016 The Scholarship Fund of the Auxiliary of Doctors Hospital was developed by
More informationAddress: Street City State Zip Code Home Phone: E-mail Address:
SANDWICH CUSD #430 REGISTRATION FORM SCHOOL YEAR 2013-2014 SELECT AN ATTENDANCE CENTER LG Haskin Prairie View WW Woodbury HE Dummer Middle School High School 1. NAME: 5. SEX: Male Female Last Name First
More information2015 Annual Patient Paperwork Update for Existing Patients
2015 Annual Patient Paperwork Update for Existing Patients DATE: ͺͺͺͺ ŚĞĐŬ WƌĞĨĞƌƌĞĚ ůŝŷŝđ &ƚ tăljŷğ 'ƌğğŷǁžžě
More informationWorker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information: Name Home Phone Address Work Phone Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status Employer No of Children
More informationCALIFORNIA WOMEN FOR AGRICULTURE SCHOLARSHIP PROGRAM
CALIFORNIA WOMEN FOR AGRICULTURE SCHOLARSHIP PROGRAM February 2016 In our continuing commitment to promote awareness and education, the Salinas Valley Chapter of California Women for Agriculture (CWA)
More informationMaine Roads Scholarship Program CDA Information 2015-2016
www.muskie.usm.maine.edu/maineroads PLEASE READ BEFORE COMPLETING APPLICATION FORM Maine Roads Scholarship Program CDA Information 2015-2016 I. DEFINITION ki i The Maine Roads Scholarship Program is a
More informationANTHC SCHOLARSHIP APPLICATION
ANTHC SCHOLARSHIP APPLICATION Fall 2014 Scholarship Application Alaska Native Tribal Health Consortium (ANTHC) is a private non-profit, tax-exempt corporation that compacts with the federal government
More informationMOPH 2013-2014 ACADEMIC YEAR SCHOLARSHIP APPLICATION PACKAGE
GENERAL INFORMATION Military Order of the Purple Heart 5413-B Backlick Road Springfield, Virginia 22151 Phone: (703) 642-5360 Fax: (703) 642-2054 or 1841 Email: scholarship@purpleheart.org MOPH 2013-2014
More informationWesleyan Pre-College Access Program
Wesleyan Pre-College Access Program What is the Pre-College Access Program? Wesleyan University s Pre-College Access Program is a comprehensive program developed to enhance the academic skills and preparation
More information2016 Scholarship Application
2016 Scholarship Application Cat Lift Trucks will award one $5,000 scholarship to an outstanding student from a public school within the Spring Branch Independent School District System (SBISD), who will
More informationWayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470
PLEASE FILL OUT THIS SHEET COMPLETELY AND CORRECTLY. PLEASE PROVIDE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY. Name Social Security # Address City, State & Zip Code Home Phone No. ( ) Cell Phone
More informationManatee Community Foundation
Manatee Community Foundation The Manatee Community Foundation was established in 1998 as a very different non-profit charitable organization that provides the opportunity for individuals to create low-cost
More information2014 Fort Worth Regional Science and Engineering Fair, University of Texas at Arlington, RadioShack. Media Release Form
2014 Fort Worth Regional Science and Engineering Fair, University of Texas at Arlington, RadioShack Media Release Form I hereby consent to and authorize the use and reproduction by Fort Worth Regional
More informationAPPLICATION FOR DONATED DENTAL SERVICES (DDS) PROGRAM
MICHIGAN DONATED DENTAL SERVICES (DDS) Dear Applicant: In response to your request for more information regarding how to apply for donated dental care, we are pleased to provide the following information
More informationSustainable Building Science Technology
Sustainable Building Science Technology Bachelor of Applied Science Program APPLICATION FOR ADMISSION FALL 2016 1 st Review Due Date: May 13, 2016 Applications received after the first review will be accepted
More informationService Academy Nomination
Service Academy Nomination Application Packet 2015-2016 Congresswoman Corrine Brown Attn: Jackie Gray Military Academy Program Director 101 East Union Street, Suite 202 Jacksonville, FL 32202 Phone 904-354-1652
More informationThese are just some of the eligibility requirements meeting these criteria does not guarantee acceptance.
BARACLUDE PATIENT ASSISTANCE PROGRAM The Baraclude Patient Assistance Program is designed to provide free medication to qualifying patients who do not have prescription drug coverage and are having a hard
More informationFOLLOW STEPS 1 6 TO COMPLETE the Sandy B. Muller Breast Cancer Foundation Application
Application Directions and Checklist Please Read Carefully Please be sure to provide all the information requested here. An incomplete application will delay our ability to provide you with assistance.
More informationJodi L. Ceballos, Psy.D. Clinical Psychologist
Hello, my name is Dr. Jodi Ceballos and I am a Licensed who recently relocated to Del Rio. I offer psychological and psycho-educational testing services, as well as individual, couples, and family therapy
More informationDeadline n Scholarships are awarded annually each spring. Scholarship applications must be received by SFM Foundation by March 31.
SFM Foundation Scholarship Scholarship guidelines Basic eligibility requirements n Must be the natural, adopted, step-child or full dependent of a worker injured or killed in a work-related accident during
More informationArt Educators, For more information contact Brenda Gregory at 813-215-8906 OR email Brenda Gregory at brenda.gregory@earthlink.net.
Art Educators, My name is Brenda Gregory and I am working directly with the Florida State Fair Art Portfolio for High School Seniors contest. We have implemented some major changes this year to make it
More informationTeena Paris DDS Program Coordinator
MISSOURI DONATED DENTAL SERVICES (DDS) In response to your recent inquiry about the availability of free or low-cost dental care, we are pleased to provide the following information about the Donated Dental
More information(This form must be used for all applications on or after 10/01/12) City, State, Zip Code Phone ( ) - Best time to contact Email
ROCKY MOUNTAIN LIONS EYE BANK EYE SURGERY FUND APPLICATION COVER SHEET To be completed by sponsoring Lions Club (See separate attachment for Application Qualifications and Procedures) (This form must be
More informationCRIME VICTIM COMPENSATION FUND APPLICATION
Office Use Only Claim No. Crime Victim Compensation Board Office of the District Attorney, 20 th Judicial District 1035 Kimbark Street, Longmont, CO 80501 Phone (303) 682-6801 Fax (303) 682-6711 CRIME
More informationPATHWAY I: Early Learning Scholarship Application
-2014 PATHWAY I: Early Learning Scholarship Application This section to be completed by the Regional Administration Office: Application Identifier #: Region: District Number and Type: Is the Family Income
More informationSTATE OF FLORIDA BOARD OF MASSAGE THERAPY APPLICATION FOR COLON HYDROTHERAPY UPGRADE TO MASSAGE THERAPIST LICENSE WITH INSTRUCTIONS
STATE OF FLORIDA BOARD OF MASSAGE THERAPY APPLICATION FOR COLON HYDROTHERAPY UPGRADE TO MASSAGE THERAPIST LICENSE WITH INSTRUCTIONS Board of Massage Therapy 4052 Bald Cypress Way, Bin # C-06 Tallahassee,
More informationCommunity Health Programs Patient Registration. Last Name: First Name: Preferred Name: Zip Code: City: State:
Community Health Programs Patient Registration Last Name: First Name: Preferred Name: Middle Initial: Suffix: Former Last Name: Gender: Male Female Date of Birth: / / Social Security Number: Mailing Address:
More informationCollegiate 100 Program Information Sheet
What is COLLEGIATE 100? Collegiate 100 Program Information Sheet The Collegiate 100 is an auxiliary organization that extends the 100's mission on college and university campuses across America. Students
More information1.Full name:... 2. Address:... Suburb/City/town... 8. Name of School/ Tertiary College/ Work Place:... Name...Ph #...
Lions Clubs New Zealand Charitable Trust CC51051 Lions Clubs New Zealand and our Heads Up for Kids project work to provide a helping hand for young people. We aim to assist New Zealand youth to perform
More information