Grant Application Pre-Screening Form
Please fill out this questionnaire to see if your child qualifies for an equipment grant. This is NOT the official grant application for requested equipment.
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
Parent/Guardian Email *
Your answer
Parent/Guardian Phone Number *
Your answer
Child First Name *
Your answer
Child Last Name *
Your answer
Is your child 21 years or younger? *
Child's Birth Date *
MM
/
DD
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YYYY
Variety-the Children's Charity of Wisconsin serves children who live in the state of Wisconsin. Is your child a resident of the state of Wisconsin? *
Does your child have a primary diagnosed physical disability? *
What is your child's physical disability? *
Your answer
What equipment will you be applying for? *
Your answer
Does your child receive any of the following services: *
Required
Variety is a charity of last resort. Have you applied for financial assistance from other sources? (Example: insurance). *
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