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  • DREW'S PUZZLE PIECE INC - APPLICATION FOR ASSISTANCE 2020

    Application Period: September 1, 2020 - October 31, 2020
  • 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
    • First page of your most recent federal income tax return or W-2
    • 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
  • Section 2

    PARENT/GUARDIAN INFORMATION
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  • Section 3

    HOUSEHOLD INFORMATION

  • Section 4

    FUNDING INFORMATION

  • Section 5

    MEDICAL INFORMATION
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  • Section 6

    REQUEST DETAILS - Complete either Part A or Part B (not both)
  • 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
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  • Section 8

    ATTACHMENTS - See documents needed under Application Requirements (page 1)
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  • 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.

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  • 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.

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  • REVIEW AND SUBMIT

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