Grant Application

Fill out the form below to apply

Next Application Cycle starts

April 1, 2018

Applications must be completed by May 15, 2018
Recipients will be announced by June 15, 2018

Contact Us To Learn More.

Jacob’s Touch Foundation is a non-profit 501(c)(3), community based organization in the Tampa Bay area, dedicated to providing CARE to families with children on the Autistic Spectrum. Jacob’s Touch serves as a resource and also provides care through referral services, grants for therapy and medical services, and education. Jacob’s Touch Foundation is proud to offer a grant program for approved therapies 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 who meet the following grant program criteria and complete the grant application will be considered for Jacob’s Touch Foundation 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 pre-approved 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, Jacob’s Touch Foundation will consider the child’s family’s dedication and involvement in their child’s treatment as an important factor in awarding grants for treatment.
Grant Amounts and Selection of Recipients
Grants of up to $5,000.00 will be allocated based on annual fundraising activities. 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, and Pasco counties). Jacob’s Touch board and grant committee selection members and their families are not eligible for treatment grants.

Applicants must demonstrate financial need by providing the following:

  • Proof of household income
  • Number of dependents and number of dependents with Autism Spectrum Disorders
  • Information about access to third-party funding sources

Provider Certification

  • Grants to be paid periodically to approved providers.
  • Jacob’s Touch Foundation 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.

The following must be submitted 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 provider of your requests, stating costs of the requested item.
  • Brief description of current family situation. Copy of previous year’s tax return.
  • Should your grant be funded, you will be asked to complete one short questionnaire regarding your experiences as a result of the funding you received. We also encourage families to share photos and stories.

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. Grants will be approved for only the following: Speech Therapy, Occupational Therapy and Applied Behavioral Analysis (ABA), direct medical costs associated with the child’s ASD diagnosis and direct educational costs associated with child’s ASD diagnosis.

Applications must be sent in by May 15, 2018.
Recipients will be announced by June 15, 2018.

Please direct any questions to: Kimmie@JacobsTouch.org.

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General Information

Dependent/Sibling Information


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YesNo

YesNo

YesNo

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 grant review process. I give Jacob’s Touch 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.







Treatment

Speech Therapy


CurrentPastNot Applicable

Occupational Therapy


CurrentPastNot Applicable

Physical Therapy


CurrentPastNot Applicable

Applied Behavioral Analysis


CurrentPastNot Applicable

Special Diets


CurrentPastNot Applicable

Biomedical Testing


CurrentPastNot Applicable

Biomedical Intervention


CurrentPastNot Applicable

Social Skills Groups


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


CurrentPastNot Applicable

Other (please explain):


CurrentPastNot Applicable

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


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Speech TherapyOccupational TherapyApplied Behavioral Analysis (ABA)Direct Medical Cost – ASD DiagnosisDirect Educational Costs – ASD Diagnosis

Financial Information



Funding Sources (including other grants and scholarship awards)

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

Private/Health Insurance
Medicaid/Other State Program
School District
Other
Other
Other

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 Jacob’s Touch to use photographs, reproductions, video tapes, recordings or endorsements of/ by me and/ or my child for publicity, fundraising or any other purpose.

I hereby grant Jacob’s Touch 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 Jacob’s Touch, 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.


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