Grant Application

Attach Documents

Please upload all documentation for consideration - this includes the Autism Diagnosis, support documents for direct treatment, financial information for both guardians, and two recommendation letters
Submitted files must be a pdf, jpg, jpeg, png, doc, docx or gif and under 4MBs to be accepted.
Attach Support Documents

Please attached copy of previous year’s tax return

Please attached copy of previous year’s tax return

Recommendation letter 1:

Recommendation letter 2:

Autism Diagnosis Form:

How did you hear about the Jacob’s Touch Foundation grant program? (please list name if referred by person)

General Information

Applicant’s Name (child affected by Autism Spectrum):

Applicant’s Date of Birth:

Applicant’s Current Age:

Applicant’s Gender:

Street Address:

City:

State:

Zip Code:

Guardian #1 Name:

Relationship:

Home Phone Number:

Cell Number:

Work Phone Number:

Email Address:

Guardian #2 Name:

Relationship:

Home Phone Number:

Cell Number:

Work Phone Number:

Email Address:

Dependent/Sibling Information

Name:

Age:

Relation to Applicant:

Autism Spectrum Diagnosis:
YesNo

Name:

Age:

Relation to Applicant:

Autism Spectrum Diagnosis:
YesNo

Name:

Age:

Relation to Applicant:

Autism Spectrum Diagnosis:
YesNo

Name:

Age:

Relation to Applicant:

Autism Spectrum Diagnosis:
YesNo

Name:

Age:

Relation to Applicant:

Autism Spectrum Diagnosis:
YesNo

History

Consent: This form authorizes the use and/ or release of the protected health information as noted below for purposes of the Jacob’s Touch Foundation grant review process. I give the Jacob’s Touch Foundation 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 Institution where diagnosed:

Phone Number:

Street Address:

City:

State:

Zip Code:

Treatment

Speech Therapy

Treatment History (check one)
CurrentPastNot Applicable

Frequency (hours/week)

Provider of Services

Occupational Therapy

Treatment History (check one)
CurrentPastNot Applicable

Frequency (hours/week)

Provider of Services

Physical Therapy

Treatment History (check one)
CurrentPastNot Applicable

Frequency (hours/week)

Provider of Services

Applied Behavioral Analysis

Treatment History (check one)
CurrentPastNot Applicable

Frequency (hours/week)

Provider of Services

Special Diets

Treatment History (check one)
CurrentPastNot Applicable

Frequency (hours/week)

Provider of Services

Social Skills/Exercise Groups

Treatment History (check one)
CurrentPastNot Applicable

Frequency (hours/week)

Provider of Services

Educational Treatment (i.e., ASD specific education)

Treatment History (check one)
CurrentPastNot Applicable

Frequency (hours/week)

Provider of Services

Other (please explain):

Explanation:

Treatment History (check one)
CurrentPastNot Applicable

Frequency (hours/week)

Provider of Services

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:

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. Please explain if this is a continuing treatment. If so, how has this treatment benefited your child? What has been the outcome from this treatment?

Direct Treatment

Total Cost of Treatment:

Grant Amount Requested for Treatment:

Supportive Documentation Attached:
YesNo

Grant request is for the following service(s)/therapies/costs (check each you are requesting):
Speech TherapyOccupational TherapyApplied Behavioral Analysis (ABA)Direct Medical Cost – ASD DiagnosisDirect Educational Costs – ASD Diagnosis

Provider Name:

Phone 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 source)

Income Amount:

Funding Sources (including other grants and scholarship awards)

Check all funding sources that apply and complete the requested information.

Private/Health Insurance

Insurance Company:

Contact Person:

Phone Number:

Treatments Covered:

Treatments NOT Covered:

Total Amounts Covered (yearly):

Total Amounts NOT Covered (yearly):

Medicaid/Other State Program

Program Name:

Contact Person:

Phone Number:

Treatments Covered:

Treatments NOT Covered:

Total Amounts Covered (yearly):

Total Amounts NOT Covered (yearly):

School District

Program Name:

Contact Person:

Phone Number:

Treatments Covered:

Other

Describe:

Contact Person:

Phone Number:

Treatments Covered:

Other

Describe:

Contact Person:

Phone Number:

Treatments Covered:

Other

Describe:

Contact Person:

Phone Number:

Treatments Covered:

Description of Family Situation

Please briefly describe in the space provided below your family situation.

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.

RELEASE AND AUTHORIZATION FOR USE OF IMAGE

I hereby release the Jacob’s Touch Foundation 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 the Jacob’s Touch Foundation 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 the Jacob’s Touch Foundation, 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. 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 and Relationship to Child:

Child’s Name:

Signature of Parent or Guardian:

Date:

Authorized Use of Name (please select one):
YesNo