Please answer all questions. If the particular question does not apply use n/a. Please complete all sections and questions, providing us with the necessary attachments; then, mail it to the address below.

SECTION I

Date_____________________________________

Teacher’s Name_________________________________________________

Name of School__________________________________________________

School Address____________________________________________________________________________

Telephone Number (including area code)_________________________

Name of Person Applying for Grant if not the teacher listed above and their Relationship to the teacher
___________________________________________________________________

Alternate Phone Number, if different from above (in case we need to reach you for questions)____________________________________

Email Address:_______________________________________________________

How did you hear about us?____________________________________________

___________________________________________________________________

Section II

How many students will this request help?___________________________

How many of the students have some form of assistance, liked SSI, Medicaid, Medicaid Waiver, etc.?______________________________________________

How many of the students are in foster care?__________________________

How many of the students live in a facility?____________________________

Are any of your students without health insurance, if so how many?___________

Is this a city or a county school?______________________________________

Is this request due to financial hardship of the teacher or the school?_________
____________________________________________________________________

Is this request due to the decline in our economy?_________________________

For instance, we know that some school systems are cutting back everywhere do make up for the price of gas for the buses. So explain the best you can.

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

What type of students do you teach?_____________________________________

List the number of students you teach in each service delivery option:

Autism __________ Other Health Impaired __________

Developmentally Delayed __________ Severe & Profound __________

Emotional Disability __________ Specific Learning Disabled __________

Educable Mentally Disabled__________ Speech & Language Imp. __________

Hearing Impaired __________ Trainable Mentally Dis. __________

Multiple Disabilities __________ Traumatic Brain Injury __________

Orthopedic Impairments __________ Visually Impaired __________

List the number of students you teach in each related service category:

Assistive Technology _________ Physical Therapy __________

Counseling Services _________ Speech & Language Ther. __________

Occupational Therapy _________ Transportation __________

How many of the students have:

ADD/ADHD _________ Down Syndrome _________

Autism _________ Incontinence _________

Cerebral Palsy _________ Mental Retardation _________

Developmental Delay _________ Other: _________

Please list the diagnoses of those listed in the “other” choice:

____________________________________________________________________

____________________________________________________________________

How many of your students use:

AFO’s/HKAFO’s ________ Mobile Pronestander _________

Crutches ________ Power Wheelchair _________

Gait Trainer ________ Stationary Pronestander _________

Manual Wheelchair ________

What item(s) are you requesting?________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

How will these items be used to meet IEP goals?___________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Will you be contributing any funds to this request?________________________

For instance, you need $100 for a project but can only afford $20.

Will the school be contributing any funds to this request?__________________

For instance, you need $100 for a project but the school will only give you $20.

Do you have a quote for the item(s) being requested:_____________________

Are you seeking funds from another source:______________________________

Would you like to receive our newsletter:________________________________

If you have visited our website did you find it helpful:______________________

What things would you like to see on our website:_________________________
____________________________________________________________________
__________________________________________________________________________________________________________________________________________

Please add any additional information that you feel might assist us in approving your grant request.

Please mail your complete grant request to: Pam Floyd, Snap4kids, 3868 Chatham Circle, Norfolk, VA 23513. If you have any questions, please email us at pam@snap4kids.org. Thank you and have a nice day!