Heart of Variety Award Request Form
Please fill out the pre-screening form carefully.
Section 1: Basic Info
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Alternate Contact
*
Alternate Number
*
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Section 2: Household Basics
Number of People in Household
*
Ages of Household Members
*
Disability Information
*
Tell us about any household members who live with a disability (age, relationship to you).
Are you the primary caregiver for anyone else in your household?
*
Yes
No
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Section 3: Request Basics
Why are you requesting funds?
*
How much funding are you requesting?
*
Eligibility Check: Do you live in Texas and have a child, youth, or young adult under 22 who lives with a disability in your household?
*
Yes
No
Severe Weather: Has your household been affected by a severe weather event?
*
Yes
No
Please tell us how and when your family was affected.
*
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Professional Note
Optional, but helpful
Upload or paste a short reference from a professional (teacher, nurse, doctor, or social worker).
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Name, Title, and Contact Information for professional reference
Would you like to share more information now to help us understand the need in Texas, or stop here and finish later?
Stop here - I only want to share the basics for now
Yes - I'd like to add more details now
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Section 5: Demographics
All optional, answers do not affect your request
Gender Identity (Head of Household)
Race/Ethnicity (Head of Household) [select all that apply]
Indigenous (e.g., Native American, First Nations, Alaska Native, Aboriginal, etc.)
Asian or Asian Heritage
Black or African Heritage
Hispanic, Latino, Latina, or Latine
Middle Eastern or North African heritage
Native Hawaiian or Other Pacific Islander
White or European heritage
Prefer not to answer
Other (list below)
Age (Head of Household)
Veteran Status
Yes
No
Prefer not to answer
Employment Status
Full-time
Part-time
Caregiver
Student
Underemployed
Unemployed
Other
Prefer not to answer
For Household Member with Disability
Gender Identity
Race/Ethnicity [select all that apply]
Indigenous (e.g., Native American, First Nations, Alaska Native, Aboriginal, etc.)
Asian or Asian Heritage
Black or African Heritage
Hispanic, Latino, Latina, or Latine
Middle Eastern or North African heritage
Native Hawaiian or Other Pacific Islander
White or European heritage
Prefer not to answer
Other (list below)
Age
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Section 6: Barriers and Supports
All optional, answers do not affect your request
Do you have health insurance?
Private
Medicaid-CHIP
Uninsured
Prefer not to answer
Do you have regular access to healthcare or therapies?
Always
Sometimes
Rarely
Never
Housing Stability
Stable
Temporary
At Risk
Unhoused
Food Security
Always enough
Sometimes not enough
Often not enough
Community Setting
Urban
Suburban
Rural
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Section 7: Follow-Up & Consent
How do you prefer we contact you for follow-up?
*
Phone
Email
Text
Would you be willing to share a note, photo, or video later about how this funding made a difference?
*
Yes
No
Do we have your permission to use your story or photo in reports to funders?
*
Yes
No
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Section 8: Confirmation
Signature
*
Submit Pre-Screening Questionnaire
Should be Empty: