Olam Piggybank Grant Application

Applicant Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Birth Date*

Age Diagnosed with a DCC*

Type of DCC*

Parent/Legal Guardian Information

Parent Name

First Last

Parent Address

Street Address Address Line 2 City 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.