Listed below are the requirements broken into two parts to apply for Andrew's Gift assistance.  Please complete Part I before proceeding to the application.  **Please note** If you have previously applied, you do not need to send additional documentation and proof of an Autism Spectrum Disorder.   

 

PART I 

PLEASE READ THE FOLLOWING OUR PRIVACY POLICY, PUBLICITY AND PHOTO RELEASE AND RELEASE AND WAIVER DOCUMENTS BEFORE PROCEEDING TO PART II.  PLEASE NOTE THAT INDIVIDUALS ARE ENTITLED TO ONE APPROVED GRANT PER CALENDAR YEAR.  ADDITIONALLY, INDIVIDUAL FINANCIAL INFORMATION MAY BE REQUESTED FOR APPROVAL.  APPLICANT IS REQUIRED TO SUBMIT DOCUMENTATION FOR PROOF OF AN AUTISM SPECTRUM DISORDER DIAGNOSIS.  THE APPLICATION CANNOT BE PROCESSED WITHOUT THIS INFORMATION.  



PART II  

An asterisk ( * ) indicates a required field 

Grant Applicant Name *
Grant Applicant Name
Address *
Address
Date of Birth *
Date of Birth
Name of Individual Completing this Application *
Name of Individual Completing this Application
Phone *
Phone
Phone number *
Phone number
Phone number *
Phone number
Applicant is required to submit documentation for proof of diagnosis for an Autism Spectrum Disorder. The application cannot be processed without this information. Forward required documentation to one of the following: • Email at andrewsgift26@gmail.com • Fax 813-741-6911 • Mail to P.O. Box 6014, Harrisburg, PA 17112
This is where you tell us what it is you want to purchase. Provide the following: • description of goods/services • name of a service provider and/or vendor along with • contact information for service provider and/or vendor ***Those applying for summer programs need to submit applications at least 2 months prior to the start of a program ***iPads are gifted 3 times a year at our iPad Days. Those receiving iPads make a commitment to attend an iPad Day and stay the entire day before leaving with the iPad. For those who need to leave early, your iPads will be held for you until the next iPad Day.
This is where you describe the person who will receive the goods or services. Tell us about • their history • the things they are good at and enjoy the most • the things that are difficult for self and others around them • their experiences at school, work & home If you are requesting goods/services to help support communication/choice please give us detailed information about how the grant applicant currently communicates
This is where you tell us • the name of other organizations that you have asked for financial help to get the requested goods/services • how much, if any, money they are providing to help pay for the requested goods/services
This is where you tell us as specifically as possible • the goals you hope to accomplish by using these goods/services • the current concerns that have caused you to seek out funds for goods/services • how you think these goods/services will be helpful to the applicant
This is where you tell us about • past experiences that tell you that your request will be helpful • if you are currently working with a professional who will be helping you use the goods/services • how the goods/services will help to support any long-term goals
This is where you provide us with notes of endorsement from professionals who helped you arrive at the decision to request the specific goods/services on this application...send all supportive documentation to any of the following - Email at andrewsgift26@gmail.com - Fax 813-741-6911 - Mail to P.O. Box 6014, Harrisburg, PA 17112
Name of application you are requesting Name of application developer Forward a letter of endorsement from a professional who is currently working with the Grant Applicant. Include the name of the professional, credentials & contact information, and a response to the following questions • What do you want the user of the app to be able to do with this app? • How is the applicant currently using the application? • What features of this application are important for this user? • What other apps were considered? • Was there a trial use of other apps? If yes, why were they not a good fit? Send letter of endorsement to any of the following Email at andrewsgift26@gmail.com Fax 813-741-6911 Mail to P.O. Box 6014, Harrisburg, PA 17112
I certify that: *
I certify that: *
I certify that: *
I certify that: *
Checking the boxes below signifies agreement with the terms and conditions contained in Part I. *
I understand that my application cannot be processed until I have submitted proper documentation regarding diagnosis. *
Andrew's Gift cannot proceed with application until proper documentation is received.

As part of its application review process, Andrew’s Gift may request additional information from the applicant including financial information.