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Buddy’s Sensory Exchange |
Application for Assistance
Guardian Information
Guardian Name:
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Address:
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Phone Number:
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Email:
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Child’s Information
Child’s Name:
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Child’s Address:
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Child’s Birth Date:
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Household Information
Child Lives With:
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Number of Guardians in Household:
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Number of Dependents in Household:
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Funding Information
Health Insurance Name
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Medicaid
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Out of Pocket Medical Expenses (Prior Year)
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Annual Family Income (Prior Year)
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Has Funding Been Received From Additional Sources? (If Yes,
List)
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Medical Information
Physician’s Name:
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Child’s Clinical Diagnosis:
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Equipment/Supplies
Type of Equipment/Supplies:
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Cost of Equipment:
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Company/Provider:
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Address:
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Phone Number:
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How will this equipment impact the child?
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For Buddy’s Sensory Exchange to consider this applicant the
undersigned to hereby affirm that:
1.
The undersigned are the parents or guardian of
the child.
2.
The undersigned agrees that if the application
is approved, that the equipment will be donated back to Buddy’s Sensory
Exchange when/if it is no longer needed by the approved child.
3.
The undersigned agrees that all information
provided is true.
Buddy’s Sensory Exchange reserves the right to distribute
funds and equipment at its sole discretion. Buddy’s Sensory Exchange may pursue
restitution for grants if it is determined the information provided is false.
I have read the guidelines for financial assistance and I
declare that the information furnished on this application is true and correct
to the best of my knowledge.
I acknowledge and agree that Buddy’s Sensory Exchange is
strictly voluntary. Furthermore, I agree to be responsible for any choices made
involving medical care, supplies or equipment, ongoing maintenance and repairs,
or malfunction as result of the grant.
Date:
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Signature:
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Printed Name:
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Media Release Consent
I hereby give my permission for Buddy’s Sensory Exchange,
and/or its representatives to use photographs, letters, videos, audio tape of
my child or myself and to use our names, information, these photographs,
letters videos, and audio tape on the internet. I understand that they will be
used to inform families, volunteers, media, and public about Buddy’s Sensory
Exchange and its programs, services, and events. I gladly give this
authorization to support the efforts of Buddy’s Sensory Exchange. This will serve
as authorization until terminated in writing.
Date:
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Signature:
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Printed Name:
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Return this application to:
December Application
3901 Blackburn Avenue
Ashland, KY 41101
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