The Safety Net Assistance Applicatiom

The Safety Net Project

Lyla's Legacy Inc.
Founded in 2025, Lyla's Legacy Inc is a 501(c)(3) charity that supports the spcial needs and disabled community. Our mission is to ease the daily challenges faced by caregivers while protecting vulnerable children/adults and empowering them to play, learn, and grow in safe, welcoming environments. Through compassion, community, and advocacy, we strive to help everyone experience the freedom and happiness they deserve. and partnerships with other agencies to magnify community impact.

Purpose: Providing life-saving resources and essential support items to families of individuals with special needs or disabilities.

How we can help: ****Note: Our Fences for Safety program will begin once sufficient funding is raised. We appreciate your patience and understanding as we work to serve as many families as possible.*****

We may also be able to assist with:

Food and basic necessities
Clothing and shoes
Sensory tools and calming items
Medical ID bracelets or medical alert gear
Specialized strollers and adaptive equipment
Safety harnesses
Child-proof locks for doors, windows, appliances, and cabinets
Indoor and outdoor safety gates
Other safety-related or support items

General Information
Name of Applicant (Parent/Guardian/Caregiver):*

PrefixFirst NameLast NameSuffix
Date

MonthDayYear
Date
Relationship to Individual with Special Needs:

ParentGrandparentLegal GuardianOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com

Individual with Special Needs Information
Name*
Age*
Diagnosis/Disability (optional but helpful for equipment planning):
Verbal Communication*

YesNoLimited
Does this individual have a history of elopement or wandering?

Request
Please describe the specific item(s) you are requesting and why it is needed. Be as detailed as possible so we can best understand your family’s needs.Note: Our Fences for Safety program will begin once sufficient funding is raised. We appreciate your patience and understanding as we work to serve as many families as possible.

0/200

Financial Need
Is your household experiencing financial difficulty? *** Optional

YesNo
Briefly describe your current financial situation (optional but helps us prioritize urgent need):

Personal Statement
Annual household income range (optional): WE DO NOT TURN AWAY ANYONE BASED ON INCOME.

Under $25,000$25,000–$50,000$50,000–$75,000Over $75,000
Number of people in household

Consent & Acknowledgment
I certify that the information provided is true and accurate to the best of my knowledge. I understand that submitting this form does not guarantee assistance, but every effort will be made to help.
Statement*

0/500

Certification
Signature (Please type your name)*
Date Completed

MonthDayYear
Application Checklist*
Optional: Would You Be Willing to Share Your Story?

YesNoOther
Should be Empty: