Jaden’s Voice Cares Grant Program Name Email address * Today's Date Primary Contact Name Description First Name * Last Name * Relationship to Applicant * Street Address * City * State/Province/Region * Zip/Postal Code * Country * Phone Number * Primary Language English Spanish Vietnamese Other Person Diagnosed with Autism First Name * Last Name * Applicant Age * Date of Birth * Gender * Female Male Other Ethnicity Black White Hispanic Asian Other This Form Authorizes the use and or release of the protected health information as noted below for purposes of the Jaden’s Voice grant review process. I give Jaden’s Voice permission to verify treatment information by contacting the treatment vendors directly. I understand that I may revoke this authorization in writing at any time. consent Yes Current Autism Spectrum Diagnosis * Date of Diagnosis * Name of Diagnosing Physician First Name * Last Name * Name of Institution * Telephone Number * City * State * Please upload Proof of Diagnosis (e.g. copy of IEP) Add Files Please include all sources of income for your household. This includes but is not limited to SI, Child Support, Adoption Assistance, other forms of Government Aid, Rental Income, etc. Please provide the latest copies of your tax returns and proof of additional sources of income. If you don't have a copy of your latest tax return, please provide your last 4 pay statements. The income threshold for individuals is $50,000 the income threshold for families is $120,000 Parent/Guardian #1 Current Annual Gross Income Parent/Guardian #2 Current Annual Gross Income Total Parent/Guardian Current Annual Gross Income * Social Security Income Other Source #1 Amount you are requesting? * Description of Need * I hereby grant Jaden’s Voice the following rights: 1. To use my/my child’s first name (you may ask that names are withheld – see below), photograph, picture, portrait, likeness, and voice in connection with its educational materials or publicity or for any other legitimate reason 2. To use, reproduce, publish, exhibit, distribute, and transmit my/my child’s image individually or in conjunction with other images or printed matter in the production of brochures, motion pictures, television tape, sound recordings, still photography, CD-ROM, and other media 3. To record, reproduce, and amplify my image and all sound effects produced I hereby release and discharge Jaden’s Voice from any and all claims, actions and demands arising out of or in connection with the use of said image, including, without limitation, any and all claims for invasion of privacy and libel. I hereby waive the right to inspect or approve my / my child’s image or any finished materials that incorporate my image. I understand and agree that I will receive no compensation, now or in the future, in connection with the use of my / my child’s image. I represent that I have read the preceding and completely understand the contents. Authorized Use of Name Yes, you can use our name No, please do not use our name I agree with the following: 1. I understand that this is a grant application and is not guaranteed funding. 2. understand that if my application is approved, funds will be distributed to the provider directly and cannot be sent directly to my family. 3. I understand that if my application is approved for a grant, the funds must be used within 12 months. 4. I agree to repay the grant if any services paid for with the grant are reimbursed by another funding source, such as a school district or insurance company. Yes
