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91886
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15569
Olam Piggybank Grant Application
Home
Olam Piggybank Grant Application
Olam Piggybank Grant Application
Natalie Piromsuk
2024-05-02T14:25:35+00:00
Applicant Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Email
*
Birth Date
*
MM slash DD slash YYYY
Age Diagnosed with a DCC
*
Type of DCC
*
Parent/Legal Guardian Information
Parent Name
First
Last
Parent Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent Phone Number
Parent Email
Family Income Range (Used as one factor to assess applications)
*
Less than 25,000
25,000 - 50,000
50,000 - 75,000
75,000 - 100,000
100,000 +
If the family income is above $75,000 please explain any mitigating circumstances that create a need for financial assistance to purchase the assistive device (e.g. large family, medical expenses or other substancial expenses)
Assistive Device
What type of assistive device is needed?
*
Link to requested device
*
Have less expensive options been considered?
*
Yes
No
Why are less expensive options not appropriate?
*
What is the estimated life of the device?
*
Will the provider provide a discount if device is purchased by a nonprofit?
*
What are the total funds required? (please include tax, shipping, etc)
If grant requested doesn't pay full amount, how will the rest of the funds be paid?
*
The Story
Story of the Appilcant
*
How have you managed without the device?
*
How will device enhance the life of the applicant
*
Any additional info relevant to the request
*
By checking the following statement the Applicant or Parent/Legal Guardian agrees:
*
The NODCC's award of this grant is not intended to constitute any recommendation or endorsement of the product described in applicant's grant application. All applicants are responsible for seeking their own professional advice regarding wheter the product is safe, approprate, and/or best suited for the applicant's use. (must select)
Must select one of the four options:
*
The NODCC can use the applicant's name, picture and story in future marketing materials
The NODCC can use the applicant's name and story but no pictures in future marketing materials
The NODCC can use the applicant's story but change their name and no pictures
The NODCC can NOT use the applicant's name, story or picture in marketing materials
I am willing to be interviewed after device is received and being used for future marketing materials
*
Yes
No
I certify that all information provided on this application is correct and accurate
*
Yes
Phone
This field is for validation purposes and should be left unchanged.
73521
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