Autism Axis Network: Family Support Grant Application
Applicants are encouraged to redact unnecessary personal information, such as insurance details, Social Security numbers, medical record numbers, and unrelated medical information.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City, State
How much are you requesting?
$250
$350
$500
How should grant funds be distributed if you are selected?
Please Select
Direct payment to me
Direct payment to a service provider
How Will You Use Funds?
Tell us about your child.
Tell us about your financial need.
Please Upload ONE of the following proofs of diagnosis documents: Diagnosis Letter or IEP Eligibility Page and Upload ONE of the following proofs of financial need: SNAP, Medicaid, SSI, Free Lunch, or Tax Return (Applicants are encouraged to redact unnecessary personal information, such as insurance details, Social Security numbers, medical record numbers, and unrelated medical information).
Upload a File
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of
Certification
I certify that the information I provided is true.
Electronic Signature
Submit Application
Submit Application
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