Believe Tablet Program Application
Complete this form for nonspeaking family members and submit updated information to maintain eligibility.
Because this application collects diagnosis information and may include documentation concerning children and disabilities, your application information will be used to determine program eligibility and will not automatically be made public. The separate media release governs what may later be shared publicly.
Family Member's Full Name
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First Name
Last Name
What is their age
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Communication status: “Is the recipient nonspeaking or minimally speaking?”
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Yes
No
Your Relationship to the Family Member
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Please Select
Parent
Guardian
Sibling
Other
Primary Diagnosis
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Please Select
Autism Spectrum Disorder
Traumatic Brain Injury (TBI)
Other
Date of Official Diagnosis
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upload Official Diagnosis Document
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Upload a File
Drag and drop files here
Choose a file
Cancel
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Additional Notes or Updates
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Your Name
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First Name
Last Name
Your Email Address
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example@example.com
Your Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
City
*
ZIP code
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County
*
Current communication method
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AAC device/app
gestures
ASL
PECS/picture communication
writing/typing
vocal speech
other
How will receiving this tablet impact your family member communication and life?
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Communication
Connection
Independence
Daily life
Family relationships
Other
Please explain specifically how this device would change the recipient’s life
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Do you want to know about more Auesomely You Cares events and resources?
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Yes
No
Previous device assistance
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Yes
No
Attendance Requirement
*
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TABLET RECIPIENT MEDIA & INTERVIEW AGREEMENT
Please read carefully. These requirements are mandatory for all selected tablet recipients.By applying for the tablet program, I understand and agree that if I/my family is selected to receive a tablet:
I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that inaccurate, incomplete, or misleading information may result in my application being denied or, if already selected, my tablet award being forfeited.
By applying for the tablet program, I understand and agree that if I/my family is selected to receive a tablet, all required acknowledgment boxes must be checked.If any required box is left unchecked, the application will be considered incomplete and will not be eligible for tablet selection.
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I understand that the interview will focus on how receiving a tablet may impact communication, connection, independence, daily life, and/or my family.
Device disclosure: if the award is a tablet only, say that AAC software, paid apps, cellular service/data plans, accessories, warranties, or ongoing technical support are not guaranteed unless specifically stated.
I must attend *Believe: An Inclusive Christmas Experience* in person and arrive *1 hour and 30 minutes before the event* for the required interview.
I authorize Leyla Strong Foundation and Auesomely You Cares Inc. to photograph, video record, audio record, and interview me and/or my child or individual for whom I have legal authority to provide consent.
I give permission for the organizations to use the interview, photographs, video, audio, testimonial, name, image, likeness, and story for nonprofit branding, websites, social media, fundraising campaigns, donor communications, grant reporting, promotional materials, advertisements, press/media, event recaps, educational materials, and other organizational marketing purposes.
I understand that brand sponsors and community partners who donate tablets or financially support the tablet program may also be permitted to use approved photographs, video clips, interviews, testimonials, and impact stories* to highlight their charitable contribution, community impact, sponsorship, or partnership with the program.
I understand that any sponsor use may include the sponsor's website, social media, community-impact reports, corporate responsibility materials, internal communications, event recaps, and related promotional or charitable-impact campaigns.
I understand that my interview and story may also be considered for publication or feature coverage by Auesomely You Magazine , including a feature article, digital story, social media feature, event recap, interview, or other editorial coverage.
I understand that participation in an interview does not guarantee publication in Auesomely You Magazine or placement in any specific issue, article, or feature.
I understand that these stories help demonstrate the impact of the organization's programs and help communicate to donors, sponsors, grantmakers, and community partners why continued funding and support are needed
If I voluntarily share that the recipient is autistic, neurodivergent, nonspeaking/minimally speaking, impacted by traumatic brain injury (TBI), or has another disability, I authorize the organizations to include that information in the approved interview/story and related marketing or editorial materials.
I understand that there will be no additional payment, royalties, or compensation for the use of the approved interview, photographs, video, audio, testimonial, or feature story.
I understand that content posted publicly, including on websites, social media, sponsor channels, and digital publications, may be shared or reposted by third parties and the organizations cannot guarantee removal of copies that have already been distributed or shared.
If I am selected and later fail to arrive at the required time, fail to attend the event, decline the required interview, or decline/refuse the required Media & Likeness Release, I will forfeit the tablet and it may be awarded to another eligible family.
I understand that completing this application does not guarantee that I will be selected to receive a tablet.
Communication status: “Is the recipient nonspeaking or minimally speaking?” with required choices. This needs to be one of your first eligibility questions since that is the purpose of the tablet program.
THIS REQUIREMENT IS MANDATORY AND NON-NEGOTIABLE.
By signing below, I confirm that I have read, understand, and voluntarily agree to the requirements above.If the recipient is under 18 years old, this agreement must be completed and signed by a parent or legal guardian. If an adult recipient has a legally appointed guardian, the authorized guardian must complete and sign the agreement.
Submitting an application does not guarantee selection. Tablet quantities are limited and recipients will be selected according to program eligibility, demonstrated need, available inventory, and program guidelines.
I confirm that I am the parent/legal guardian or otherwise legally authorized to give consent for the recipient when necessary.
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I confirm
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