2025 Individual Grant Application

Contact Name(Required)

First Last

Contact Email(Required)

Contact Phone(Required)

Alternate Phone(Required)

Please do not use your work phone number

Alternate Email(Required)

Please do not use your work email address

Mailing Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Gender(Required)

Male

Female

Prefer not to answer

Provide a Diagnosis(Required)

Please provide a brief description of the diagnosis of the individual(s) for whom you are applying for the grant.

Upload diagnosis documentation(Required)

Please upload documentation to provide proof of the diagnosis/diagnoses of the individual(s) for whom you are seeking the grant.

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Requested Item

iPad Speech Tablet

Sensory Items (Please provide a list in the field below)

Other (Please provide a description in the field below)

If your child uses a speech tablet at school, what is the software he or she uses? (If you do not know, please enter N/A)(Required)

Sensory Items List(Required)

Please provide a list of items along with links to the site from which the item(s) may be purchased (e.g. amazon.com, Walmart.com, etc.)

Other Requested Item(s)(Required)

Please provide a list of items along with links to the site from which the item(s) may be purchased (e.g. amazon.com, Walmart.com, etc.) Please Note that follow up questions may come from a member of our staff prior to approval.

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2025 Individual Grant Application

Mailing Address

Remote Admin

Email