Application for Individuals

Grant Application for Individuals

Grants are reviewed on a monthly basis.
Proof of Autism diagnosis should be submitted with all applications (Doctor’s note, OPWDD Statement, IEP Cover Page, etc.).
Applications without sufficient information will not be considered until the packet is complete.
Checks will be made out to the provider and sent to you unless paid invoice is included.

"*" indicates required fields

My grant request falls within the following area.*

Recreational/Arts

Educational

Social

Therapeutic

Not sure

If you're not sure, please tell us what your are requesting.*

Name, address, phone number and email of person who is filling out this application.*

This is who the check will be sent to.

Name of individual who will be receiving the grant.*

First Last

The check should be payable to*

(Please include name and address of organization or service)

Program, service or materials for which you are applying. Include name of organization if applicable.*

Do you have an invoice for the service or items requested.*

Yes

Has applicant's insurance been billed?*

Yes

Not applicable

Do you have any of the following? Check all that apply.

Medicaid Waiver

OPWDD Approval

Self Direction

ACCES-VR

(This will not affect your application)

Amount requested*

(Please be aware partial payment may be granted.)

There may be some circumstances where you have already paid for materials or a service and are looking for reimbursement. If that is the case, please explain, submit your receipt and your grant will be considered.

Upload required documentation for diagnosis

Max. file size: 50 MB.

Upload required documentation for invoices/receipts

Drop files here or

Max. file size: 50 MB.

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