ASF Family Fund Application

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number*

Email*

Name of the individual(s) with Angelman syndrome that the ASF Family Fund grant award would benefit.*

Birthdate of individual*

Proof of an Angelman syndrome diagnosis is required.

THIS IS REQUIRED for your application to be considered. If you need time to obtain, you can email the document to kely@angelman.org by the 14th.

Accepted documents include genetic results or something from a doctor that indicates an Angelman syndrome diagnosis.

Drop files here or

Max. file size: 50 MB.

Does the individual with AS have a Deeming Waiver?*

Yes
No

Your relationship to the Individual(s) with Angelman Syndrome.*

Specify relationship.*

Are you the primary caregiver of the individual(s) with AS?*

Yes
No

I, myself, or a family member has/have applied for scholarship funding from ASF previously on behalf of the individual with AS named in this application.*

Yes
No

Please select the category associated with your ASF Family Fund request in this application.*

I have contacted an ASF Clinic and know my financial responsibility should I be awarded a grant to travel to a clinic.*

Yes
No

Select the type of communication device

Select the software/app

I understand that replacement parts are my responsibility.*

I understand

I understand that I will be required to show a receipt for a communication app purchase once gift card is received.*

I understand

Please attach evidence that insurance or school system as denied this item.

Drop files here or

Max. file size: 50 MB.

Please select from one of the following. Links to examples below.*

Copy and paste link in browser. Safe Place Travel Bed: https://safeplacebedding.com/products/safe-place-travel-bed-blue-bed-only | Abrams Nation Safety Sleeper 200: https://www.adaptivespecialties.com/abram-s-nation-the-safety-sleeper-200-model.aspx | Safe Place Permanent Bed: https://safeplacebedding.com/products/safe-place-permanent-slandered-beds

Specify the type of recreational equipment*

Specify the medical equipment*

Please describe or explain the medical equipment.*

Have you applied for this medical equipment through insurance?*

Yes
No

Please attach evidence that insurance has denied this item.

Some applications may not be approved without an insurance denial.

Drop files here or

Max. file size: 50 MB.

What you are applying for? Please be as specific as possible.*

I understand that I will be responsible for ordering.*

I understand

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/1000 characters

Please indicate that you understand each of these statements.

Please be advised . . .

For applicants outside of the United States