DREW'S PUZZLE PIECE INC: APPLICATION FOR ASSISTANCE

DREW'S PUZZLE PIECE INC

Application for Assistance
Drew's Puzzle Piece Inc is a 501(c)(3) non-profit organizaiton. Our mission is to help Greater Cincinnati families affected by autism obtain items and services they need. Items may include, but are not limited to therapies, assistive technology and safety supports.
APPLICATION REQUIREMENTS

Every application must have the following to be processed:
- Documentation child is of age 21 or younger (birth certificate, passport, medical records, etc)
- Documentation of Autism diagnosis from physician on letterhead
- Letter from parent or guardian, detailing need and any other previous grants awarded
- Proof of residency in one of the following Greater Cincinnati Counties
  - Ohio: Hamilton, Clermont, Butler, Warren
  - Kentucky: Boone, Kenton, Campbell, Grant, Pendelton, Gallatin
  - Indiana: Dearborn
The following items are optional to provide:
- Letter detailing need from Special Education teacher or therapist (Speech, Occupational, ABA, Developmental Intervion)
- Child's Photograph (please see the media release section below)
CONTACT INFORMATION

Emily Michels - Vice President

Phone: (859) 835-6158

Email: dppinc@outlook.com

Website: www.dppinc.org

Facebook: https://www.facebook.com/DPPINC.ORG/

Mail: Drew's Puzzle Piece Inc

PO Box 175856

Ft. Mitchell, KY 41017-5856

Section 1

CHILD INFORMATION
Child's Name*

First NameMiddle NameLast NameSuffix
Child's Birth Date*

MonthDayYear
Gender*

MaleFemale
Do you have more than one child with autism in your household?*

YesNo
If yes, please list the name, age, birthday and gender of additional children here:

Section 2

PARENT/GUARDIAN INFORMATION
1. Parent/Guardian*

First NameMiddle NameLast NameSuffix
Relationship to the child*
Occupation*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Email*
example@example.com
Primary Phone Number*

Area CodePhone Number
2. Parent/Guardian

First NameMiddle NameLast NameSuffix
Relationship to the child
Occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Email
example@example.com
Primary Phone Number

Area CodePhone Number

Section 5

MEDICAL INFORMATION
Primary Physician*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email (If Available)
example@example.com
Case Manager Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Child's Clinical Diagnosis (eg: Autism Spectrum Disorder)*
Child's age at the time of diagnosis
Section 6

REQUEST DETAILS - Complete either Part A or Part B (not both)
PART A - REQUEST FOR TREATMENT/SERVICES
Type of Treatment/Services
Purpose of Treatment/Services
Brief Description
Number treatments or visits
Cost per treatment or visit
Amount in USD
Price after discount from provider
Amount in USD
PART B: REQUEST FOR EQUIPMENT/SUPPLIES
Type of Equipment or Supplies
Purpose of Equipment/Supplies
Brief Description
Cost of Equipment/Supplies
Amount in USD
Price after discount
Amount in USD

Section 7

PAYMENT INFORMATION
Grant funds will not be given directly to the applicant. If the Application is approved, Drew's Puzzle Piece Inc will provide payment via one of the following:
- Direct payment to company or service provider for Treatment/Services
- Direct purchase from company for Equipment/Supplies
Check made payable to:
Company or Service Provider
Attention to Name
Person or Department receiving the check
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Company Name for Online Purchase
Product Name
Model Number
Website/Link
Additional Relevant Information
Section 8

ATTACHMENTS - See documents needed under Application Requirements (page 1)
If you prefer to send all required documents via USPS, please indicate below

Yes, I will send my documents via USPS to Drew's Puzzle Piece Inc, PO Box 175856, Fort Mitchell, KY 41017-5856
Age Documentation

Browse Files
Eg: Copy of Birth Certificate, Passport, Medical Records, etc Cancelof
Diagnosis

Browse Files
Letter from physician on letterhead Cancelof
Parent/Guardian Letter

Browse Files
Letter detailing need and any other grants awarded Cancelof
Tax Return or W-2

Browse Files
First page of federal income tax return or W-2 Cancelof
Proof of Residency

Browse Files

Cancelof
Letter from Special Education Teacher or Therapist

Browse Files
Optional Cancelof
Child's Photograph

Browse Files
Not required Cancelof

Section 9

CONSENT TO RELEASE INFORMATION
I do hereby authorize all hospitals, financial institutions, and insurance groups to release to Drew’s Puzzle Piece Inc, or its duly authorized representatives, any information deemed necessary to complete its investigation of my application for financial assistance. In addition, I do hereby authorize all hospitals, financial institutions, and insurance groups to release to Drew’s Puzzle Piece Inc, or its duly authorized representatives, any information or itemized statements that pertain to the diagnosis and treatment of the child and related expenses. I further authorize Drew’s Puzzle Piece Inc and its representatives to provide such information to those institutions as may be reasonably required to assist our family and our child. All consents given herein shall continue until such time as the undersigned provides notice of termination in writing.
Section 10

AFFIRMATION OF INFORMATION PROVIDED
IN ORDER FOR DREW'S PUZZLE PIECE INC, A 501(c)(3) NON-PROFIT ORGANIZATION, TO ADVANCE SUPPLEMENTAL FAMILY SUPPORT EXPENSES IN CONJUNCTION WITH THE MEDICAL TREATMENT OF THE CHILD (REFERENCED IN SECTION 1 OF THIS FORM), I DO HEREBY AFFIRM AS FOLLOWS:
1. The undersigned are the parent(s) or guardian(s) of the child.
2. The undersigned further agree(s) to return any unused funds immediately to Drew's Puzzle Piece Inc so that those funds can be utilized by the organization to benefit other families.
3. The undersigned acknowledge(s) and agree(s) to maintain records that will be made available to Drew's Puzzle Piece Inc upon reasonable request, detailing the expenditures made from the funds provided by the organization.
I have read the guidelines for financial assistance and I declare that the information furnished on this application form, including attached or mailed sheets, is true and correct to the best of my knowledge. (Please refer to the checklist at the top of page one of the application and attach all required documentation prior to submitting the application.)

When awarding a grant, Drew's Puzzle Piece Inc is not advocating for the specific health care providers or equipment suppliers, but only providing the funds to enable you to access the services and equipment. You acknowledge and agree that accepting a grant from Drew's Puzzle Inc is strictly voluntary. Furthermore, you agree that you will be responsible for any choices you make regarding the medical care, equipment or supplies, or for the failure, malfunction, repairs, or ongoing maintenance of any equipment obtained as a result of the grant of funds.
Parent/Guardian Signature*
Please type name*
Parent/Guardian Name
Date*

MonthDayYear
Date
Parent/Guardian Signature (If 2 Parents/Guardians)
Please type name
Parent/Gaurdain Name
Date

MonthDayYear
Date
Section 11

MEDIA RELEASE CONSENT
***Signing the media release form is not a requirement in order to receive assistance from Drew's Puzzle Piece Inc***

I hereby give my permission for Drew’s Puzzle Piece, Inc and/or its representatives to use photographs, audio tape recordings, letters, information or videos of my child or myself and to use our names, information, these images or voice recordings in publications, slides, videos, on the Internet. I understand they will be used to inform families, volunteers, media and the general public about Drew's Puzzle Piece Inc and its services or events. I give this authorization to support the efforts of Drew's Puzzle Piece Inc. I understand this authorization shall continue until terminated in writing.
Accept or Decline*
Parent/Guardian Signature (if accepting)
Please type name
Parent/Guardian Name
Date

MonthDayYear
Date
REVIEW AND SUBMIT
Please verify that you are human*
Should be Empty:

DREW'S PUZZLE PIECE INC

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Section 11

REVIEW AND SUBMIT