Grant Application Form

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 NameLast Name
Child's Birth Date

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / 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 NameLast Name
Name of Spouse/Second Parent if applicable*

First NameLast 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 childLetter 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
Tax Information *

Cancelof
Photo Upload*

Cancelof
Letter of Need from a medical professional*

Cancelof
Quote of exact piece of equipment from manufacturer*

Cancelof
I hereby agree that the information given is true, accurate and complete as of the date of this application submission. **

YES
Should be Empty:

Grant Application Form

Initial Request for Support

Parent or Guardian Information