Lawyers Autism Awareness Foundation Treatment Grant Notice

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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

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