Special Angels Foundation Mini Grant Program

Please review the above 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 official diagnosis, and documentation that shows their need. Please attach documentation to your application before submission. Grant cannot be processed without requested documentation. If your request is for equipment, please provide the name or the type of the item. Any questions please contact us via email @ specialangelsfoundation@gmail.com

Name of Child With Special Needs

First Name Last Name

Date of Birth

Sex

Male or Female

Age of your child (under 18 yrs)

eligible up to age 18

Tell us about your child's special needs? *

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

What are you seeking a grant for?*

Co-pays and deductible max is $1000

Grant amount you are seeking*

Max Grant for equipment is up to $2500, Max Grant for therapy is up to $1500. You can’t apply for both.

Please provide the name, address and phone number of your medical insurance provider.*

i.e., Medical insurance, Regional Center or CCS

Have you applied for therapy or equipment with your medical insurance/Regional Center or CCS ?*

YESNO

If you answered YES to the question above, tell us why your were denied *

Reason for Denial

If you answered NO, please tell us why your haven't applied to your medical insurance, Regional Center or CCS for your request*

Reason you haven't applied for your requested item.

If you are requesting assistance with a co-pay or deductible, please provide the cost per session or the deductible for the requested service. We do not provide funds for reimbursement for services already provided.*

Please don't provide your yearly deductible.

If you are requesting therapy, please provide the name, address and contact person to the facility you are requesting therapy from.*

If applying for computer, please provide the name and type of computer used in school. If the device is for summer school, please attach your child's summer classes.*

Please provide computer type and summer school schedule

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

How did you hear about us?*

Social Media, word of mouth ??

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. Special Angels Foundation may use your child's photo or video for advertisement purposes.

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.

6. By signing this application, you give Special Angels Foundation permission to contact your child's physician, if deemed necessary, to assist in processing your application.

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

RELEASE OF LIABILITY SIGNATURE

We can process your application until we receive proof of your child's disability. Please upload now Clear

Date

Upload files here*

Browse Files

Proof of child's disability must be uploaded or provided to process your application

SAF Grant Application