Avery Lake Relief Fund Application Questionnaire
Families for Inclusion is honored to announce a brand-new program designed to support families during their most difficult and unexpected moments.The Avery Lake Relief Fund was created to provide emergency financial assistance to individuals with special needs and their families. Whether facing a sudden hardship, navigating insurance denials for essential equipment, or coping with the unimaginable loss of a loved one, this fund exists to help bridge the gap when families need it most.💛 Examples of eligible situations include:• Bereavement support• Emergency needs related to a disability• Insurance denials for adaptive or medical equipment• Unexpected financial hardships directly impacting a special needs individual. Applications are accepted year-round — 365 days a year — while funds last. All applications will be reviewed and approved by our Board of Directors. Please note: the amount requested may not be the amount granted, as awards are based on available funding and individual circumstances. Our hope is that no family feels alone during an emergency and that this fund provides comfort, dignity, and support when it matters most.
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Individual with Special Needs:
Full Name of Individual with Special Needs:
Age of Individual with Special Needs:
Primary Diagnosis/Condition:
Please describe the emergency or hardship you are experiencing.
Date the emergency occurred (if applicable):
How has this situation impacted the individual with special needs?
Is this emergency related to one of the following? (Check all that apply)
Bereavement
Insurance denial of medical/adaptive equipment
Unexpected financial hardship
Other (please explain)
If Other, please explain:
Have you applied for assistance from any other organization for this situation?
Yes (please list below)
No
Please list other organizations:
Amount you are requesting:
Please provide a detailed explanation of how the requested funds will be used:
Have you received financial support from Families for Inclusion before? If yes please explain:
Are you able to contribute any portion of the cost yourself?
Upload any supporting documentation (insurance denials, invoices, receipts, etc.).
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Is there anything else you believe our Board of Directors should know when reviewing your application?
What is the best way to contact you if additional information is needed?
Please read and acknowledge the following: I understand that all applications will be reviewed and approved by the Families for Inclusion Board of Directors. I understand that the amount requested may not be the amount granted. I understand that applications are accepted year-round while funds last. I certify that all information provided in this application is true and accurate.
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