Grant Application

Please answer all questions. If the particular question does not apply to your child, use n/a. Please complete all sections and questions, providing us with the necessary attachments; then, mail it to the address below.

SECTION I

Date_____________________________________

Child's Name_________________________________________________

Child's Date of Birth________________________

Child's Address____________________________________________________________________________

Telephone Number (including area code)_________________________

Name of Person Applying for Grant on Behalf of Child, and their Relationship to Child

___________________________________________

Phone Number, if different than Child's (in case we need to reach you for questions)_______________

Section II

Does your child receive SSI?  ( )yes  or  ( )no

Does your child receive Medicaid?  ( )yes  or  ( )no

If yes, is medicaid the primary or secondary insurance?  ( )Primary  or  ( )Secondary

If yes, is it a waiver program?  ( )yes  or  ( )no

If yes, what type of waiver?_________________________

If yes, is it a HMO?  ( )yes  or  ( )no

If it is a HMO, are you happy with them?  ( )yes  or  ( )no

If you are not happy with your HMO, please explain.______________________________________________________________________

Does your child have any other health insurance?  ( )yes  or  ( )no

If yes, are you satisfied with the service you are getting?  ( )yes  or  ( )no

If you are not happy with your health insurance, please explain_____________________________________________________________

Does your child have school accident insurance?  ( )yes  or  ( )no

Section III

Can your child walk unassisted?  ( )yes  or  ( )no

Can your child walk assisted?  ( )yes  or  ( )no

Can your child crawl?  ( )yes  or  ( )no

Can your child feed him/her self?  ( )yes  or  ( )no

Can your child sit unsupported?  ( )yes  or  ( )no

Can your child sit supported?  ( )yes  or  ( )no

Can your child assist with transfers?  ( )yes  or  ( )no

Can your child talk/communicate with others?  ( )yes  or  ( )no

Does your child receive physical therapy?  ( )yes  or  ( )no

Does your child receive occupational therapy?  ( )yes  or  ( )no

Does your child receive speech therapy?  ( )yes  or  ( )no

Does your child receive any other any other form of therapy?  ( )yes  or  ( )no

If yes, please specify what kind_______________________________________

Has your child had surgery?  ( )yes  or  ( )no

If yes, how many?__________

Is your child on medication?  ( )yes  or  ( )no

Does your child have any allergies?  ( )yes  or  ( )no

Does your child have seizures?  ( )yes  or  ( )no

Has your child been diagnosed with developmental delay?  ( )yes  or  ( )no

Has your child been diagnosed with autism?  ( )yes  or  ( )no

Has your child been diagnosed with mental retardation?  ( )yes  or  ( )no

Has your child been diagnosed with cerebral palsy?  ( )yes  or  ( )no

Has your child been diagnosed with down syndrome?  ( )yes  or  ( )no

Has your child been diagnosed with incontinence?  ( )yes  or  ( )no

Has your child been diagnosed with adhd?  ( )yes  or  ( )no

Please list any other medical diagnoses that your child has.___________________________________________________________

Does your child use pull-ups, diapers, briefs, underpads, etc?  ( )yes  or  ( )no

Does your insurance cover the diapers?  ( )yes  or  ( )no

If yes, what insurance covers the diapers?___________________________________________________

Does your child use a manual wheelchair?  ( )yes  or  ( )no

Does your child use a power wheelchair?  ( )yes  or  ( )no

Does your child use a gait trainer?  ( )yes  or  ( )no

Does your child use a mobile prone stander?  ( )yes  or  ( )no

Does your child use a stationary prone stander?  ( )yes  or  ( )no

Does your child use a mobility stroller?  ( )yes  or  ( )no

Does your child use afo's/hkafo's?  ( )yes  or  ( )no

Does your child use a tens machine?  ( )yes  or  ( )no

Does your child use a tes machine?  ( )yes  or  ( )no

Does your child use crutches?  ( )yes  or  ( )no

Does your child use a specialized car seat?  ( )yes  or  ( )no

Does your child use a abductor wedge?  ( )yes  or  ( )no

Does your child see a neurologist?  ( )yes  or  ( )no

Does your child see a orthopedic surgeon?  ( )yes  or  ( )no

Does your child see a pediatrician?  ( )yes  or  ( )no

Does your child see a gastrologist?  ( )yes  or  ( )no

Does your child see a neurosurgeon?  ( )yes  or  ( )no

Does your child see a endocrinologist?  ( )yes  or  ( )no

Does your child see a pulmonary doctor?  ( )yes  or  ( )no

Does your child see a physical medicine and rehabilitation doctor?  ( )yes  or  ( )no

Please list any other specialists that your child sees._______________________________________________________________

If your child is in a wheelchair, does he/she have a wheelchair ramp at home?  ( )yes  or  ( )no

If your child is in a wheelchair, does he/she have a vehicle equipped with a wheelchair ramp?  ( )yes  or  ( )no

If your child is in a wheelchair, is it handicapped accessible?  ( )yes  or  ( )no

Does your child have an IEP?  ( )yes  or  ( )no

Does your child receive respite?  ( )yes  or  ( )no

Does your child receive nursing services?  ( )yes  or  ( )no

What equipment does your child currently need?

________________________________________________________________________

Do you foresee obtaining the above listed equipment from your health insurance?  ( )yes  or  ( )no

Has your health insurance (whether primary or secondary) denied any equipment for your child?
( )yes  or  ( )no

SECTION IV

What item(s) are you requesting a grant for?________________________________________________________________

List the medical diagnosis that applies to the item(s) requested._________________________

Do you have a certificate of medical necessity for the requested item?  ( )yes  or  ( )no

Do you have a quote for the item requested?  ( )yes  or  ( )no

Do you have a letter of medical necessity for the item requested?  ( )yes  or  ( )no

Do you have a evaluation for the item requested?  ( )yes  or  ( )no

Do you have a denial from your insurance for the requested item?  ( )yes  or  ( )no

Why are you requesting a grant from Snap4kids for the above item(s)?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

SECTION V

How did you hear about us?___________________________________________________

_____________________________________

Would you like to receive our newsletter?  ( )yes  or  ( )no

What is your email address?_____________________@_____________________________

Do you mind if we send you email updates?  ( )Please send updates  or  ( )Do NOT send updates

Have you ever visited our web site, at www.snap4kids.org?  ( )yes  or  ( )no

Did you find it helpful?  ( )yes  or  ( )no

Anything else you want to add?___________________________________________________________________________________

______________________________________________________________________________________________________________

Mail your grant request and the necessary documentation to: Snap4kids, 520 W. 21st Street, Unit G-2/706, Norfolk, VA 23517.

Please include a letter of medical necessity for the item being requested.

Please include a price sheet and/or order form for the item being requested.

Please send a photo of the child that the item is being requested for.

Remember, the more medical documentation we have, the better.

Also, if you have a denial from your insurance company, we need that too. Some items do not require a letter of denial (because universally, all insurance companies do not cover particular items. However, with more insurance companies more items to save money, if you do not attach a denial from your insurance company, then we must have a denial from your child's doctor or therapist as to why the item is not covered under your health insurance plan(s).