The ASF Family Fund was created to assist families supporting individuals with Angelman syndrome. The goal of the ASF Family Fund is to allow families to apply for funds to assist in gaining access to resources that are needed to improve the quality of life for an individual with Angelman Syndrome. Please indicate that you understand each of these statements.I understand that if I have already received a grant in the last three years, I am not eligible to receive the grant this cycle.* I understand I understand that by submitting this scholarship application I / my family will be fairly considered for an ASF Family Fund grant award.* I understand I understand that I/my family may incur additional expenses which are my/my family’s responsibility.* I understand. I understand that if I do receive an ASF Family Fund grant award, I will be asked to submit an impact story that could be shared with others.* I understand. I understand that I may assume the tax burden associated with the ASF Family Fund request.* I understand. I understand that one application will be accepted on behalf of the individual(s) with Angelman Syndrome.* I understand. I understand that each ASF Family Fund grant award will be for approved items up to total cost of no more than $5,000 (including any applicable sales tax and/or shipping and handling costs).* I understand. Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone number*Email* Name of the individual(s) with Angelman syndrome that the ASF Family Fund grant award would benefit.*Proof of an Angelman syndrome diagnosis is requested. If you have proof available now, please attach it here.If you need time to obtain, you can email the document to firstname.lastname@example.org by October 30. Accepted documents include genetic results or something from a doctor that indicates an Angelman syndrome diagnosis. Drop files here or Your relationship to the Individual(s) with Angelman Syndrome.*Select RelationshipParentGrandparentRelativeSiblingOtherSpecify relationship.*Are you the primary caregiver of the individual(s) with AS?*YesNoPlease select the category associated with your ASF Family Fund request in this application.*15q Network Clinic Visit (travel to/from and/or lodging)Communication Device/SoftwareRecreational EquipmentSafety Bed / Travel Safety BedMedical EquipmentTherapyOtherSelect the type of communication deviceiPad miniOtherSelect the software/appProloquo2goPODDTouchChatOtherSpecify the type of recreational equipment*Bike/TricycleRunning ChairTrailerOtherSpecify the medical equipment*WheelchairCar SeatActivity ChairWalkerBath SeatRampOtherWhat you are applying for?*Please attach evidence that insurance has denied this item.Some applications may not be approved without an insurance denial. Drop files here or Please provide details of what you are seeking funding for.*Please include a description, website and any other specific information (size, product version . . . ).How would receiving this grant impact the Individual(s) with Angelman syndrome? Please be as specific as possible.*minimum 200 words Gross Annual Income:*0 - $30K per year$30K-$60K per year$60-$100K per year$100K-$200K per year$200K+ per yearTotal number of dependent individuals currently residing within your home:*12345OtherSpecify number of dependents*Proof of cost/expense for this ASF Family Fund request.*Please attach a document, screenshot or photo from the vendor that lists or shows the cost of the item. Drop files here or Are you able/willing to contribute an amount towards the purchase of the item requested.*Your answer will NOT affect the consideration of your application in any way. If you have raised some funds already for your request, or are able to contribute even a small portion of the cost, then it helps our ASF Family Fund dollars go farther, and in turn helps more individuals with Angelman syndrome.YesNoHow much can you contribute?*Please be advised . . .The Angelman Syndrome Foundation has established partnerships with several vendors that provide us with a direct discount on items when purchased in bulk. This requires items to be purchased by ASF and sent directly to the award recipient. Therefore, if you apply for a specific item, you may be offered a similar item from an ASF partner vendor, or the choice to use that dollar amount in the form of an ASF Family Fund grant (via reimbursement after you purchase the item) to apply toward the comparable item in your application.Recognition*I certify that the information presented on this application is accurate and truthful, to the best of my knowledge. Failure to provide accurate and truthful information will result in my application being disqualified from consideration. Additionally, I fully understand that failure to submit a complete application will automatically disqualify my application for consideration during the current ASF Family Fund grant cycle. Yes, I certify that the information presented is accurate and truthful. CAPTCHACommentsThis field is for validation purposes and should be left unchanged.