2019 LEAP Application Form

About LEAP Awards
The Arc of Northern Virginia supported by a grant from The HSC Pediatric Center is excited to offer the 2022 LEAP Awards (Life Enrichment Awards Program) to support goods and services directly linked to youth and young adults with disabilities and chronic illnesses engaged in transition planning and implementation that are usually not available from public service and government agencies. These goods and services must not be covered by Medicaid or private insurance and are not considered "medically necessary".

Examples include, but are not limited to:
- Skills camps or classes
- Instruction or fees for starting a business
- Assistive technology to improve academic or professional opportunities
- Computer hardware or software
- Tutoring
- Independent living skills training
- Business clothing
Eligibility Requirements:
- Must be between the ages of 14 and 26
- Must not have received a LEAP grant within the past three years
- Must have a documented disability
- Must reside in The Arc of Northern Virginia's service area: Arlington and Fairfax Counties or the Cities of Alexandria, Falls Church, or Fairfax
Application Deadline August 15, 2022

Award Notification:
Applicants will be notified of results by phone and/or email by August 24th. Once an applicant is selected to receive a LEAP Award, The Arc of Northern Virginia will coordinate with the applicant and their family, caregiver or representative, to make arrangements for the award.

Questions: Contact Diane Monnig, Director of Programs at dmonnig@thearcofnova.org or 703-208-1119 ext. 118.

Deadline: August 15, 2022

Note: Please review all of the application questions below and required documents that need to be included.

Documents you will need to upload with your submission include the following: Documentation of Disability and Supporting Documentation regarding the items or services you are requesting (i.e. course catalog description of desired class; docmentation from the vendor outlining services with associated fees; web page description of laptop, IPad, etc.)

If you need any assistance with this online application or have any questions, please contact Diane Monnig at 703-208-1119 ext. 118 dmonnig@thearcofnova.org
1. Information on Transitioning Youth
Name *

First Name Last Name
Age *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number of Applicant *

Area Code Phone Number
Please check one or more areas listed below which correlate to your disability: *

Intellectual disability Hearing impairments (including deafness) Speech or language impairments Visual impairments (including blindess) Serious emotional disturbance Orthopedic impairments Autism Traumatic brain injury Other health experiencing delays
Have you previously received a LEAP Award? *

Yes No
If yes, when was the LEAP Award received?
Year
2. Information on Family Member or Support Person Completing this application
Name *

First Name Last Name
Relationship to Youth *
Title
If applicable, i.e. Support Coordinator, Case Manager
Organization
If applicable
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail: *
Amount Requested *
Maximum $1000
Please describe the item, service, or opportunity you are requesting. You may attach a photo or document describing the item if needed *
Please attach supporting documentation such as photos or documents related to the items you would like to purchase, classes or other services you would like to purchase. *

Browse Files

Cancel of
Describe how this item or service will assist your transition to adult hood. Please provide specific examples of what you will be able to do or accomplish by receiving this award. *(minimum 150 words) *

0/200
Please give any additional information that may be of help in processing this request.
4. Vendor/Provider Contact Information

Provide information on the service provider or vendor where the award will be purchased. For example BestBuy.com for the purchase of a computer, Northern Virginia Community College for classes, etc. Attach any supporting documentation that will be helpful. The Arc of Northern Virginia will purchase the goods and services directly on your behalf.
Name of Company or Organization where goods or services will be purchased *
Name of Contact at the Organization (if applicable)
Address (if applicable)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Web Address (if applicable)
i.e. BestBuy.com
Email of Vendor Contact
example@example.com
Phone Number of Vendor Contact

Area Code Phone Number
Should be Empty:

1. Information on Transitioning Youth

2. Information on Family Member or Support Person Completing this application

4. Vendor/Provider Contact Information