Family Grants Application Form

All required fields are marked with an asterisk (*).

 

I. E-Mail Address of Applicant

* E-mail:

II. Family Information

Mother's Name
Address
Phone (Day)
Phone (Evening)
E-mail Address
Occupation
Father's Name
Address (If different)
Phone (Day)
Phone (Evening)
E-mail Address
Occupation

III. Information about the Child

Name of Child with Disability
Date of Birth
Grade in School

This section below is required. Please check all boxes.

My child has been diagnosed with Asperger Syndrome, High Functioning Autism or a closely related condition within the autism spectrum
My child is age 22 or under
My child lives at home

IV. Request for Funds

* Amount Requested:

* What will you use the funds for?
Any additional information or special circumstances that you wish to add to your request for a grant

V. Family Financial Information

* Total taxed family income earned and unearned, before taxes (please send us a copy of page 1 of your latest tax return)
Are you receiving SSI for your child? Yes   No
Have you received family support funds this year from any other agency? Yes   No

VI. The Check

* The check should be made out to:

* The check should be sent to:


VII. Conflict of Interest / Agreement

I agree that the child does not have any relationship with the organization (the Doug Flutie, Jr. Foundation Trustees, the Flutie family, OR the Phillips Foundation Trustees, Mr. Phillips, or his family) or any other contributor to the organization or any other corporation controlled by any other contributor to the organization.

I have read and completed this grant application and certify that the information contained in it is correct to the best of my knowledge and best of my belief. I certify that I have made a diligent search for other sources of funding for this request and that, to the best of my knowledge, there are no other resources, public or private, available to fulfill this request.

* Please check here if you agree to these terms.

VII. Additional Materials Required (can be mailed or faxed to AANE)

  • First page of your most current completed tax return (or documentation from SSI, SSDI, Unemployment Income, or Transitional Assistance if you are not required to file a tax return).
  • Recent official document with child’s diagnosis.

Mailing Address:

Asperger's Association of New England (AANE)
51 Water St., Suite 206
Watertown, MA 02472

Fax: (617) 393-3827