Individual Grant Application

PCWSN Charity logo

30905  E Stoney Point School Rd

Grain Valley, MO 64029

CRITERIA FOR INDIVIDUAL FUNDING
Parenting Children with Special Needs may provide available funds for resources needed:

1.) for the provision of direct service for children:

A.    With Special needs

B.   Under the age of 21

C.   Within the Greater Kansas City area

 

2. ) For a specific medical need or piece of equipment

3. ) For emergency financial needs for parents

4.) For prevention

5.) For mobility

 

Parenting Children With Special Needs does not provide funding for

1.) Research

2.) Capital Campaigns

3.) Building Funds

 

APPROVAL CYCLE

Upon request, application forms for funds request will be sent to individuals.

Received Application:

1.) Applications for fund request will be forwarded to the appropriate committee chairperson

2. ) The Committee will have up to 4 months after they receive to meet, review the application, visit the application for an in-home evaluation, and agree upon a recommendation.

3.) The Committee Chair will bring the recommendations to the next scheduled board meeting of the Parenting Children with Special Needs- Board of Directors for discussing and approval/denial.

4.) The application will be notified of the Boards determination within one week of the Board meeting

5.) Awarded funds will be remitted within one month of notification. Mobility equipment will be ordered immediately upon approval of request and will be delivered in the earliest possible timeframe

 

TERMS OF AGREEMENT FOR SUPPORTED INDIVIDUALS

1.) Mobility Request are limited to wheelchairs, ramps, lifts, walkers, bicycles, etc, at this time.

2.) Funds and Mobility Equipment must be used in compliance with purpose(s) stated in the application. The use of the funds or Mobility Equipment for other needs must be approved by Parenting Children With Special Needs in writing.

3.) The funded individual (and family) will assist with the promotion of Parenting Children With Special Needs by allowing:

A.     The use of the individual(s) and family name(s) in any/all Variety of Greater Kansas City Printed Material, press release, PSA’s, websites, social media, etc.

B .    When not in conflict with

—   the use of photographs or film of the child(ren) and/or family to whom it provides service for publication in printed material, promotion videos, TV spots, websites, etc.

—   personal appearances by child(ren) and families receiving services.

4.) Applicants requesting individual funding will allow a member(s) of Parenting Children With Special needs to visit the home for an in-home evaluation.

5.) A Parenting Children with Special Needs representative will be in attendance to take pictures during the check presentation or at time of delivery of Mobility equipment.

6.) If all the terms of this agreement are met, it will be the responsibility of Parenting Children with Special needs to provide such funding as awarded per the appropriate Committee to the individual as approved by the Board within the time frame agreed upon.

7.) If for any reason, Parenting Children with Special needs, Inc. ceased to exist, all terms of the agreement will be null and void. If this will occur, Parenting Children with Special Needs will attempt to distribute whatever funds it may have available to local agencies for children with of special needs.

Note:

Parenting Children with Special Needs recognizes and encourages the efforts of the individual to raise funds in other ways. The funded individual is therefore invited to support Parenting Children with Special Needs through public awareness, participation in fundraising activities, and special events for children, etc. 

**At this time we are only accepting Kansas City Grant Application**

Child's Information







Family's Information





















Medical Information (Physician associate with current care)









Complete The Portion Being Requested

Parenting Children with Special needs Inc. reserves the right to distribute funds at its discretion. Please indicate the exact address of where funds will be sent. Parenting Children with Special Needs will send money directly to the treatment provider, the equipment company, hospital, etc and not directly to the recipient family. A discount MUST be given for any request in order to be considered for funding

Request

Which fields would you like to view?

Services (Surgeries, clinic visits, therapy, etc)









Medication











Equipment








Travel













Food

Parenting Children with Special Needs, inc will provide $10 per day for food (Maximum of two individuals)









Lodging

Parenting Children with Special Needs, inc will provide $10 per day for food (Maximum of two individuals)










Required- Consent to release information and affirmation

I do hereby authorize all hospitals, financial institutions, and insurance groups to release to Parenting Children with Special needs, Inc or its duly authorized representatives, any information deemed necessary to complete its investigation of my application for financial assistance. In addition, I do hereby authorize all hospitals, financial institutions, and insurance groups to release to Parenting Children with Special Needs, inc, or its duly authorized representatives, any information or itemized statement that pertain to the diagnosis and treatment of the child and related expenses. I further authorize Parenting Children with Special needs Inc, and its representatives to provide such information to those institutions as may be reasonably required to assist our family and our child. All consents given herein shall continue until such time as the undersigned provides notice of termination in writing.

In order for Parenting Children with Special Needs Inc Charity., a non-profit organization to advance supplemental family support expenses in conjunction with the medical treatment of (child), the undersigned do hereby affirm as follows:

1.) The undersigned are the parents or guardians of the child
2.) The term "non-medical expenses" is understood to mean lodging, food, gas, parking, and transportation for children who require treatment incurred by the family or guardian of the above-named child in conjunction with that child receiving medical treatment. Finacial assistance will be provided with the use of said funds to be specified by Parenting Children with Special Needs, Inc.
3.) The undersigned acknowledge(s) and agree(s) to maintain records that will be made available to Parenting Children with Special Needs, Inc. upon reasonable request, detailing the expenditures made from the funds provided by the organization.

Parenting Children with Special Needs Inc. may pursue restitution for grants if it is determined that the information submitted on the application is false.

I have read the guidelines for financial assistance and I declare that the information furnished on this application form, including attached sheets, is true and correct to the best of my knowledge. (Please refer to the checklist at the top of page one of the application and attach documents Below)

Attach Documents here

When awarding a grant, Parenting Children with Special Needs inc is not advocating for the specific health care providers or medical equipment supplies, but, only providing the funds to enable you to access the services and equipment. You acknowledge and agree that accepting a grant from Parenting Children with Special needs, Inc is strictly voluntary. Furthermore, you agree that you will be responsible for any choices you make regarding the medical care, equipment or supplies, or for the failure, malfunction, repair or ongoing maintenance of any equipment obtained as a result of the grant of funds.

Media Release Consent

I hereby give my permission for Parenting Children with Special Needs, Inc and/or its representative to use photographs, audio tape recording, letters, information or videotape of my child or myself and to use our names, information, these images or voice recordings in publications, internet, social media, or motion pictures.

I understand they will be used to inform families, volunteers, media and the general public about Parenting Children with Special Needs, Inc and programs, services, or events. I gladly give this authorization to support the efforts of Parenting Children with Special Needs, Inc. I understand authorization shall continue until terminated in writing. Check box below to show your understanding.

Please check the box to agree that you fully read, understand, and consent to ALL terms outlined above and hold Parenting Children with Special Needs no liable for any circumstance outlined above.