Special Angels Foundation Mini Grant Program

Please review the grant requirements prior to filling out your application.

All application sections must be completed in order to be considered for a grant. If all fields are not completed, your application WILL NOT be reviewed for consideration. Note: This grant is only for equipment or therapy for the benefit of the child. Application must include your childs diagnosis, on your childs doctors letterhead, documentation that shows the need. Please send documentation at time of grant request. Grant cannot be processed without requested documentation. Please email your documents to specialangelsfoundation@gmail.com. If your request is for equipment, please provide the name of the item, cost and vendor contact information. Any questions please contact us via email.

Parent / Guardian Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Area Code Phone Number

Name of Child With Special Needs

First Name Last Name

Date of Birth

Age of your child (under 18 yrs)

Tell us about your child's special needs?

Is the request for a medically prescribed item/service or an item/service that would improve quality of life? *

Medically prescribed Quality of life

Have you been turned down for support for therapy or equipment? *

YES NO

If you answered yes to the question above, tell us why your were denied and please provide us with the denial letter.

Please provide the name, address and phone number to your child's pediatrician.

What are you seeking a grant for?

Therapy, equipment or other support

Please tell us the cost of the equipment or therapy you are requesting through the Special Angels Foundation Grant Program? *

Does the applicant have medical insurance that covers the requested equipment/service? If yes, please provide the insurance company name and the amount of your deductible.

RELEASE OF LIABILITY Special Angels Foundation is a nonprofit organization with the purpose of improving the lives of children with special needs. Through the Mini Grant Program, Special Angels Foundation provides financial assistance for Equipment, Therapies and other supplies to grant recipients. By signing this document, I agree as follows:

1. Condition “As Is”: Special Angels Foundation is not making any representations, warranties, or guarantees about the Item(s) or therapy including any implied warranties of merchantability. In response to my application for a Mini-Grant, Special Angels Foundation is donating to me an item or therapy. I am accepting the donated Item(s) “as-is.” I understand that Special Angels Foundation will not provide any instructions or follow-up services, replacement parts, or repairs.

2. Assumption of Risk: I understand that there are certain risks of injury that may arise from the possession, use or misuse of the donated Item(s) or therapies, including the risk of injury, disability, or death of my child or other persons, or damage to property. I assume full responsibility for all risks arising directly or indirectly from my possession, use or misuse of the donated Item(s) or therapies, both known and unknown, regardless of the cause.

3. Waiver and Release: I waive and release any and all claims against Special Angels Foundation, its officers, agents and employees (collectively, "Client Parties") with respect to any and all injury, disability, death, loss or damage to property resulting from possession, use or misuse of the donated items or therapies, regardless of the cause and even if caused by negligence, whether passive or active. I agree not to sue any of the Client Parties on the basis of these waived and released claims. I waive the protections of Section 1542 of the California Civil Code, which provides that a general release does not extend to certain claims not known to me at the time I signed this document.

4. Indemnity: I will defend, indemnify and hold Special Angels Foundation harmless from and against any and all liability, loss, damages, claims and attorney’s fees that may be suffered by me and/or my grant recipient resulting directly or indirectly from the possession, use or misuse of the donated items or therapies by me or any other person, except and only to the extent the liability is caused by the gross negligence or willful misconduct of a Client Party.

5. I have read and understand the terms of this agreement. I understand that this agreement covers each and every item I am receiving. I sign it freely and voluntarily.

To insure you are a live person please type the word that you see in the box below *

RELEASE OF LIABILITY

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Special Angels Foundation Grant Application