Grant Application Form
Initial Request for Support
Please note that Variety's grants are for children 18 and under with disabilities and are need-based. Additional documentation will be required for final approval. Support is based on funds available and dependent on the number of applications received. Application for funds does not guarantee support.
Name of Child
*
First Name
Last Name
Child's Birth Date
Please select a month
January
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Month
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Day
Please select a year
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Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Variety DC's focus is on children with mobility disabilities
*
Check if mobility disability is present
Describe your child's diagnosis:
Describe product or service being requested :
For example: Adaptive bicycle, partial support for an adaptive van, scholarship support for therapy service, etc. The request must be for something that a therapist feels is essential but insurance will not cover.
Parent or Guardian Information
Name of Applying Parent/Guardian
*
First Name
Last Name
Name of Spouse/Second Parent if applicable
*
First Name
Last Name
Primary Phone
*
Relationship to Child
*
E-mail
*
example@example.com
2022 Household Annual Income
*
Your application cannot be reviewed without the following documents. Please send the following information to leigh@varietydc.org. If the Grants Committee moves forward with your request, we will send you a liability release form and a photo release form:
*
Financial information such as tax returns, SSI, unemployment, child support, SNAP, etc.
Photo of the child
Letter of need from medical profession. Can be from a doctor, nurse, therapist, school nurse, who has professional contact with the child and can verify the diagnosis and explain why the equipment or service can benefit the child.
Quote for exact item requested
I hereby agree that the information given is true, accurate and complete as of the date of this application submission. *
*
YES
Send Application Now
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