Online iPad Application
Please note the following:
• if you are making requests for multiple children you will need to complete an application for each child
• requests for specialized AAC applications must be accompanied by information submitted by a professional working with the applicant
• cases are included with your iPad
Applications without the following information will be treated as an incomplete application and will not be processed until this information is provided:
• supporting documentation of an autism spectrum disorder diagnosis
• financial information
iPads received through our grant program will be distributed at our iPad Days. These days occur twice a year and provide an opportunity for caregivers to set-up their iPads and work with a variety of professionals in setting goals for it’s use. Please note that the parent and/or professional attending the iPad Day is expected to stay for the entire day of training. For those who need to leave early, the iPad will be held for you until the next iPad Day. iPads must be received within one year of the application approval or a new application must be submitted.
Our iPad Days are scheduled as follows:
• 1st Saturday in March (snow day the 2nd Saturday in March)
• 3rd Saturday in October.
Our iPad Days occur at:
The Vista School
1021 Springboard Drive
Hershey, PA 17033
All applicants will be notified when an application is received. Grant applications are reviewed quarterly (January, April, July, October). Applicants will be notified of status of grant approval soon after the grant review committee meets.
Please read the following documents before proceeding to Part II.
Consent for Use and Disclosure of Confidential Information
PUBLICITY AND PHOTO RELEASE
By acknowledging this Publicity and Photo Release where indicated in the application, I hereby grant to Andrew’s Gift the absolute and irrevocable right and unrestricted permission to use the name, likeness, image, voice, and/or appearance of the Applicant as such may be embodied in any photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of Andrew’s Gift or its partners and affiliates. I agree that Andrew’s Gift has complete ownership of such material and can us said material for any purpose consistent with the mission of Andrew’s Gift. These uses include, but are not limited to, videos, publications, advertisements, news releases, websites, and any promotional or educational materials in any medium. I acknowledge that the Applicant will not receive any compensation for the use of such images, video, likeness, etc. By acknowledging this Publicity and Photo Release where indicated in the application, I hereby release and discharge Andrew’s Gift, and its agents, representatives and assigns, from any and all claims and demands arising out of or in connection with the use of the Applicant’s name, likeness, image, voice and/or appearance, including any and all claims for invasion of privacy, right of publicity, misappropriation or misuse of image and/or defamation. By acknowledging this Publicity and Photo Release where indicated in the application, I represent that I am at least 18 years old and that I have read the forgoing and fully understand its contents. If the Applicant is younger than 18 years old, then I hereby certify that I am the parent or legal guardian of the Applicant and do hereby give my consent without reservation to the foregoing on behalf of the Applicant. By acknowledging this Publicity and Photo Release where indicated in the application, I agree that this release shall be binding upon me and my heirs, legal representatives and assigns (and in the case of an Applicant that is younger than 18 years old, upon the Applicant and his heirs, legal representative and assigns). This agreement is made and entered into under the laws of the Commonwealth of Pennsylvania and shall be governed and interpreted in accordance with the laws of the Commonwealth. This agreement embodies the entire agreement of the parties. No modification of this agreement shall be of any effect unless it is made in writing and signed by all the parties to the agreement.
RELEASE AND WAIVER OF LIABILITY PLEASE READ CAREFULLY!
THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS!
This Release and Waiver of Liability (the “Release”) is executed as of the application date by the applicant (the “Grant Recipient”) or the parent or legal guardian of the Grant Recipient, in favor of Andrew’s Gift, a Pennsylvania nonprofit corporation and its directors, officers, employees, and agents. The Grant Recipient has applied for a grant from Andrew’s Gift to engage in activities funded through an award by Andrew’s Gift (the “Activities”). The Grand Recipient understand that the Activities may include physical activities, exposure to hazardous conditions and other circumstances that may result in personal injuries. The Grant Recipient hereby freely, voluntarily and without duress Releases Andrew’s Gift under the following terms:
1.Release and Waiver. By acknowledging this Release and Waiver where indicated in the application, Grant Recipient does hereby release and forever discharge and hold harmless Andrew’s Gift and its succors and assigns fro any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, that arise or may hereafter arise from Grant Recipient’s Activities with a vendor or service provider funded through a grant by Andrew’s Gift.
GRANT RECIPIENT UNDERSTANDS THAT THIS RELEASE DISCHARGES ANDREW’S GIFT FROM ANY LIABILITY OR CLAIM THAT THE GRANT RECIPIENT MAY HAVE AGAINST ANDREW’S GIFT WITH RESPECT TO ANY BODILY INJURY, PERSONAL INJURY, ILLNESS, DEATH, OR PROPERTY DAMAGE THAT MAY RESULT FROM GRANT RECIPIENT’S ACTIVITIES FUNDED THROUGH A GRANT BYANDREW’S GIFT, WHETHER CAUSED BY THE NEGLIGENCE OR WILLFUL CONDUCT OF ANDREW’S GIFT OR ITS OFFICERS, DIRECTORS, EMPLOYEES OR AGENTS OR OTHERWISE. GRANT RECIPIENT ALSO UNDERSTANDS THAT ANDREW’S GIFT DOES NOT ASSUME ANY RESPONSIBIITY FOR OR OBLIGATION TO PROVIDE FINANACIAL ASSISTANCE OR OTHER ASSISTANCE INCLUDING BUT NOT LIMITED TO MEDICAL, HEALTH, OR DISABILITY INSURANCE IN THE EVENT OF INJURY OR ILLNESS.
2. Medical Treatment. By acknowledging this Release and Waiver where indicated in the application, Grant Recipient does hereby release and forever discharge Andrew’s Gift from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with the Grant Recipient’s Activities funded by a grant from Andrew’s Gift.
3. Assumption of the Risk. Grant Recipient understands that the Activities may involve work that may be hazardous to the Grant Recipient, including, but not limited to, physical activities, exposure to hazardous conditions, or other circumstances that may result in personal injuries, and transportation to and from the Activities’ sites. By acknowledging this Release and Waiver where indicated in the application, Grant Recipient hereby expressly and specifically assumes the risk of injury or harm in the Activities and releases Andrew’s Gift from all liability for injury, illness, death, or property damage resulting from the Activities.
4. Insurance. Grant Recipient understands that Andrew’s Gift does not carry or maintain health, medical, or disability insurance coverage for any grant recipient. Each Grant Recipient is expected and encouraged to obtain his or her own medical or health insurance coverage.
5. Governing Law; Validity. By acknowledging this Release and Waiver where indicated in the application, Grant Recipient expressly agrees that this Release is entitled to be as broad and inclusive as permitted by the laws of the Commonwealth of Pennsylvania and that this Release shall be governed by and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. Grant Recipient also agrees that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this release, which shall continue to be enforceable.
6. Grant Recipient Under 18. If the Grant Recipient is younger than 18 years old, then the person acknowledging this Release and Waiver where indicated in the application hereby certifies that he or she is the parent or legal guardian of the Grant Recipient and does hereby give this Release and Waiver without reservation on behalf of the Applicant.