Autism Fund Application
Email address *
Name of Receipient *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Guardian Name *
Your answer
Street Address *
Your answer
City, State and Zip Code *
Your answer
Email
Your answer
Phone Number
Your answer
ASD Diagnosis/Date (Please attach diagnosis and or IEP
Your answer
Medical Facility
Your answer
Describe Need (Please provide support documentation and letter of recommendation from healthcare or education representative)
Your answer
How much does your need require? (Please note that any equipment purchased for recipients with needs are to be returned to LAF when there is no longer a need)
Your answer
How much personal funds can you provide toward this need? Please provide reasons if any.
Your answer
How much personal funds can you provide toward this need? Please provide reasons if any.
Your answer
Have you applied to LAF previously?
If Yes, how much previously applied for?
Your answer
Amount received?
Your answer
What were the funds used for?
Your answer
Does the recipient and guardian have private insurance?
If Yes, through who?
Your answer
Please list all state and/or Federal assistance types and amounts available to recipient and guardian (example: SSI, Badgercare, etc)
Your answer
Has recipient been enrolled in any county services and/or waivers? If Yes, please list waiver/service and estimated date for redemption.
Your answer
Has recipient been enrolled in any county services and/or waivers? If Yes, please list waiver/service and estimated date for redemption.
Your answer
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