Loud Mommy iPad Grant Application by L3Yaq6O

VIEWS: 19 PAGES: 5

									                                           Loud Mommy
                                        www.loudmommy.com
                                       loudmommy@gmail.com

Loud Mommy realizes how difficult it is for parents of Non-Verbal children to get iPads for their children, on top of the
expenses for therapy, medical treatment, medical equipment and other services needed. In keeping with our mission and
our commitment to help nonverbal children, we have developed an iPad program to assist deserving families in getting
this device and AAC applications for their child—which their insurance company and school system has either denied or
will not cover.
                                           Grant Application Guidelines

The grant is awarded based on need, and will be given out as funds are raised. The grant is awarded at the sole
discretion of Loud Mommy Ministries Grant Committee, and also depends on the funds that are available within the
foundation. The recipient must use the iPad for the purposes stated on their application form.

All applications are confidential.
                                                         Criteria

To apply for the Loud Mommy iPad program:

       We ask that your child is between the ages of 2 and 12 years old, but at this time we are accepting applications
        from children up to 18 years of age.
       Your child must have a diagnosis of autism or apraxia of speech and be nonverbal
       To allow us to help as many families as possible, we ask that there be a limit of one application submitted per
        family

If your case meets the above criteria, you must complete a grant application along with the following:

       A completed financial worksheet
       A photo of your child along with signed consent/refusal to allow Loud Mommy to put your child’s story/picture on
        our website or to be used with our fundraising efforts
       Documentation of your child’s diagnosis—letter/report from their doctor (on official letterhead)

The application is the most important step in the evaluation process and we want to give all applications the consideration
they deserve, so we ask that all questions and sections are answered thoroughly and completely. Any missing
documentation will automatically make your application incomplete, and you will be considered ineligible for our grant
program until all the necessary information/documentation has been completed and received.

If you have any questions you may contact us at loudmommy@gmail.com




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                                             Loud Mommy
                                          www.loudmommy.com
                                         loudmommy@gmail.com

                                            Grant Application
                                       Please fill out completely and legibly

                                                                                   Application date ____________

How did you hear about Loud Mommy’s iPad program: _________________________________________________

______________________________________________________________________________________________

                                             Candidate Information

Child’s Name: ____________________________________________________________

Age:__________________ Date of Birth _____________________ Sex ____________

Diagnosis: ______________________________________________________________

When was your child diagnosed: _____________________________________________

Physician’s Name: ________________________________________________________

If you have insurance, does it cover any of your child's therapies: ____________________________________

Out of pocket medical expenses in the last year for your child: $ ______________

Does your child currently receive any government assistance? If so, please list: ______________________

______________________________________________________________________________________

                                               Family Information

Mother’s Full Name: _______________________________

Address: _______________________________________ City _________________________

State _________ Zip code: __________

Phone Number: (______) _________________

Email address: ______________________________________

Occupation: ____________________________Place of Employment: ________________________________


Father’s Full Name: ________________________________

Address: _______________________________________ City _________________________
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    State _________ Zip code: ___________

    Phone Number: (______) _________________

    Email address: ______________________________________

    Occupation: ______________________________Place of Employment: ________________________________

    Annual Household Income (including both parents): $_______________

    If applicable: Annual Child Support or Alimony: $__________________

    Name and ages of any siblings: _________________________________________________________

    __________________________________________________________________________________

                                                 iPad Request Information

Please answer these questions on a separate sheet of paper and attach to the application. Please answer each question
thoroughly and in as much detail as possible.
Section A: Background information
    1. Tell us about your family.
    2. Tell us your child’s story.
    3. Tell us about the discovery of your child’s disability and how it has affected your family. Specifically share how
        Verbal or Non-Verbal your child is. This is EXTREMELY important.
    4. Tell us about the treatment/therapies your child is currently doing (or has done in the past). How did your child
        benefit, and what types of improvements did you see?
    5. Tell us about your child’s health insurance coverage, and describe any challenges you’ve had in getting them to
        cover any medical equipment or a treatment/therapy.
Section B: Grant Request
    1. Please describe why you are requesting funding, and what the iPad will be used for.
            a. Have you applied for an iPad with any other organization? (If so, which organization(s) and what was the
                 result?)
            b. If your child is in school, why isn’t the school providing an AAC device? (Have you asked them to and
                 what was the result?)
            c. Who will assist you and your child in utilizing the iPad as an AAC and a learning device by providing
                 training and help?
            d. Are you familiar with iTunes? Do you have an account? Will you be able to load applications?
    2. Has an AAC device been suggested or used before and if so, which one and why was it suggested/used?
    3. How do you envision the iPad improving your child’s life?
    4. Any additional information that is relevant to the request
    5. If chosen, may we share your story on our website to help with fund-raising efforts, spreading awareness and
        encourage other parents who may be in a similar situation?




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                                              Financial Worksheet
**ALL INFORMATION IS CONFIDENTIAL AND WILL NOT BE SHARED WITH ANYONE**
Household:
Number of adults in home: ______          Number of children in home (including candidate) _____

Gross Monthly Household Income:

    No Income:
                                    □                         Any other government assistance:     $__________
    Salary and Wages:               $__________
    Child Support:                  $__________               Veteran’s Benefits:                  $__________
    Alimony:                        $__________               Worker’s Compensation:               $__________
    Welfare:                        $__________               Other Disability:                    $__________
    SSI (you and/or your spouse)    $__________               Unemployment:                        $__________
    SSI: (your child):              $__________               Other Income:                        $__________
                                                                                                                     Total
                                   Household monthly gross income: $ _____________

Monthly Expenses:
Total Debt (excluding mortgage), i.e. credit cards, student loans, car payments: $ _______________
List all debt and your monthly payments:

_____________________           _____________________            ____________________

_____________________           _____________________            ____________________

_____________________           _____________________            ____________________

_____________________           _____________________            ____________________

_____________________           _____________________            ____________________

Rent: $ ____________
Mortgage: $_________
Monthly out-of-pocket medical expenses: $ ___________
Monthly child care expenses (including all siblings): $ _______________
Other Monthly expenses: $ _________________

Assets:
Checking Account $ ___________
Savings Account: $ ___________
Investments: $ ___________
Trusts: $ _______________
Other Assets: $____________

Please use the below space to include any additional financial information for your grant application. (you may also attach
a separate sheet of paper if necessary.)
__________________________________________________________________________________________________




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I hereby certify that all of the information submitted in this application and all statements that I have made are true. I also
certify that any false information or omission of facts may result in cancellation or immediate dismissal of my application,
and will prohibit my child from ever re-applying for a grant through this program in the future. Loud Mommy Ministries
reserves the right to take any necessary action to recover funds that were awarded and not used for what they were
intended for as stated in the above application.

Signature: _______________________________________________

Date: ______________________

            Please submit your grant application and other requested documentation to:


                                                Loud Mommy
                                                P.O. Box 114
                                              Sparland, IL 61565
                                **Please send regular mail—NOT CERTIFIED MAIL**

                              What happens after you submit your application?
After you submit your application, it will be reviewed by our Grant Committee. We wish that we could purchase an iPad
for all of the applicants. Please do not email regarding the status of your grant application. Loud Mommy will contact
you, should any additional questions arise.
                                                    Consent Form
As part of our new grant program, we would like to start posting the pictures and stories of the children that our
foundation has been able to help. Please indicate below granting your consent/refusal to possibly post your child’s picture
and story.


______I do NOT want my child’s picture/name/story to be posted on Loud Mommy’s website
_____ You MAY post my child’s picture/name/story on your website
_____ You MAY post my child’s picture/name/story on your website but please change his/her first name
_____ I would like to blog for www.loudmommy.com about my experiences with autism/apraxia.
_____ I would like to help fund-raise for Loud Mommy Ministries.

.
Printed Name______________________________________________

Signature _________________________________________________

Date: ________________________




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