Grant Application

Child's Name

First NameLast Name

Child's Diagnosis

Parent/Guardian Name

First NameLast Name

Which therapy clinics are your child currently receiving treatments through? (please specify treatments/therapists if possible)

Please let us know what specific items or services you are requesting The Broom Tree to help provide, along with their associated costs. Explain how these will benefit your child or family. Include any special needs or equipment your child requires, such as adaptive strollers, medical equipment, seating devices, fenced enclosures, etc., along with possible costs.

What services does your child currently receive? (SSI, OCDD, Medicaid, etc)

Have you applied for or received help from The Broom Tree before?

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

TERMS AND CONDITIONS

Broom Tree Application: By filling out this application, I understand that I am NOT guaranteed assistance or approval for funds.

I am aware that Broom Tree will use this application to determine eligibility for assistance with accommodations, equipment, and/or other needs of my child that cannot be provided through already available resources (including, but not limited to SSI, Medicaid, OCDD funds, private insurance, etc).
I am aware that Broom Tree is not guaranteeing 100% payment of needs and that approval of application is based on resources available at any given time, approval of the Broom Tree board, and interview with the family.
I understand that any approval for assistance from Broom Tree will be determined including, but not limited to the following requirements:
Child must have a diagnosed condition from current pediatrician or other medical professional that affects the daily life of the child.
Child is a resident of Rapides Parish.
I am aware that Broom Tree is responsible for raising the funds held by the non-profit organization and, therefore, holds all rights to funding distribution.
If my child is chosen as a Broom Tree assistance recipient, I give permission for Broom Tree to publish photos, name of child (with diagnosis) and use updates both on social media and other publications to encourage further community involvement and fund raising opportunities for the growth of the Broom Tree community.
I understand that if my child is not chosen with this application, we can reapply yearly as long as the following terms are still met: Diagnois/condition still applies, Child is still a resident of Rapides Parish, Child/family has not received funds within the last years s

Submit applications to broomtreecenla@gmail.com or 493 Burma Rd Ball, LA 71405

All submitted applications will only be viewed by members of the Broom Tree board. Your signature below indicates that you agree to all statements above.

Child’s Full Name: _______________________________________________________

Signature & Date

Please verify that you are human*