We Bee-lieve Grant Application

We Bee-lieve Grant Application - Parent Form

The We Bee-lieve Grant is designed to help families with out of pocket expenses related to physical, occupational, and speech therapy services and adaptive equipment purchases. The maximum amount families can apply for per quarter is $1000. Proof of statement balance and/or equipment cost will be required. Verification from therapist or physician that adaptive equipment purchase is safe and appropriate for child will be required. Payment will be made directly to therapy clinic/vendor. Addilynn's Bee-lievers reserves the right to approve an amount different than what is requested based on number of applications and funds available.
Parent Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Amount Requested up to $1000
What will grant funds be used for?

Physical Therapy ServicesOccupational Therapy ServicesSpeech Therapy ServicesAdaptive Equipment Purchase
Type of adaptive equipment being purchased
Therapy Clinic/Vendor Contact Information - include name, address, email, phone number, invoice number
File Upload

If applying for funds to be applied to PT, OT, and SLP services, upload copy of most recent billing statement. If applying for funds for adaptive equipment, upload a letter from a therapist or physician order affirming this is a safe and appropriate piece of equipment for your child.
Cancelof
My e-signature below indicates I understand and agree with the following
- I will be informed of application approval/denial by email 1 week after the application period closes.
- Addilynn's Bee-lievers may approve an amount different than what I request. The amount approved will depend on applications received and funds available.
- Payment will be made directly to clinic/vendor.
- I give my permission to my child's therapy clinic, therapist, and/or primary care physician to verify to Addilynn's Bee-lievers that I have out of pocket expenses from therapy services rendered and/or that the equipment requested is safe and appropriate for my child.
- Incomplete applications will not be considered.
- I understand that preference will be given to applicants who have not applied during current fiscal year.
Signature

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We Bee-lieve Grant Application - Parent Form