PCF Application

Who Can Receive Assistance?

Families who live in Hancock County and surrounding counties (Allen, Auglaize, Crawford, Hancock, Hardin, Henry, Marion, Putnam, Sandusky, Seneca, Van Wert, Wood & Wyandot)
Any individual with a diagnosed disability, there is no age limit. The child or individual must be diagnosed as having a physical, mental or emotional disability.

What Type of Assistance Do We Provide?

Monetary Assistance to offset the cost of therapy and programs.
Activities which might be awarded assistance but not limited to, include Art Therapy, Music Therapy, Water Therapy, Horseback Riding, Social Groups, Ice Skating, Dance, and Occupational Therapy.
Monetary Assistance is not intended for everyday medical expenses. This is designed for outside experiences to enrich the life of the individual.

How Much Assistance Do We Provide?

Pierce's Crew will consider Scholarship award amounts based on merit, the number of applicants and the availability of funds. Currently, the limit per individual is $600.00 per year.
If a scholarship is awarded the money will be paid directly to the service provider or vendor/organization providing the program or therapy.

How Are Assistance Decisions Made?

Pierce's Crew Foundation Board Members make the decision based on the needs of each applicant.
The Members review a completed application and approves assistance on an as needed basis. Award are contingent on funds available and number of applications per application period.

How Can I Receive An Application And When Is The Deadline?

Log onto our website, PiercesCrew.org, to fill out your application.
Our application deadlines are as follows: April 30, August 31 and December 31.

How Will I Know If Assistance Has Been Awarded Or Not?

We will send you a letter in the mail letting you know whether you will be awarded or denied.

Scholarship Checklist

These items will need to be uploaded at the end of this application.

A copy of an IEP or letter from the applicant's licensed Clinical, Therapist or Doctor.
Proof of Address. A copy of a household bill, of the applicant's or the parent's driver's license.
Bill or estimated cost of requested therapy or program from the provider.

Other Information

Applications are all reviewed after the deadline. For example, if you submit for the April 30th deadline, applications will be reviewed at the next board meeting in May. Please give us 30 days from deadline to send out your letter.

Applicant Information

Applicant Name*

First NameLast Name

Applicant Address*

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code

Date of Birth*

Date of Birth

Gender

Parent, Caregiver or Guardian's Inforamtion

Relationship to Applicant*

Relationship to Applicant

Name*

First NameLast Name

Address if different from Applicant

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code

Home Phone Number

Please enter a valid phone number.

Mobile Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Diagnosis and Assistance Request

Applicant's story and diagnosis:*

Therapy or program requested*

Name of Provider*

Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Provider Phone Number*

Please enter a valid phone number.

Estimated Cost of Therapy or Program*

Length of Time*

Your Estimate Contribution*

Have you looked into other assistance?*

Participated in Therapy or Program Before?*

If yes how long?

List any received funds/assistance from any other sources (Social Security, DD, BCMH, etc)

Fun Information

Please tell us about your child or individual (likes, accomplishments, etc)

How will this request improve the child or individual's life?

How did you hear about Pierce's Crew Foundation*

Supporting Documentation

Please upload the requested supporting documentation.

IEP or Letter File Upload*

Proof of Address File Upload*

Bill or Estimate of Requested Services File Upload*

Final Information

If assistance is awarded, Pierce’s Crew Foundation cannot guarantee appropriateness, or the safety of the service requested by the applicant. Pierce’s Crew Foundation is not responsible for the safety or progress of the child or individual. Please consult your physician and/therapist regarding what is best for your child or the individual.

Pierce’s Crew Foundation will not share your name or any information given on or with your application.

I hereby certify that all above information submitted and the statements I have made are true and agree that any false information, misrepresentation, or omission of facts may result in cancellation or immediate dismissal of my application.

I understand that any monetary assistance provided will go directly to the provider of said therapy or program.*

Yes

Please add me to the mailing list.*

YesNo

I am interested in volunteering! Please contact me.*

YesNo

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