Name of Applicant: (required) Age: (required) Name of Parent/Guardian/Other applying for Applicant: (required) Your Email (required) Phone Number (required) (1) Type of Cerebral Palsy (please highlight all that apply): (required) Spastic QuadriplegiaSpastic TriplegiaSpastic DiplegiaSpastic HemiplegiaSpastic MonoplegiaAthetosisAtaxiaDystonia (2) Have you applied to the JGL Foundation for a grant in the past 3 years? yesno (3) Are you Applying for a grant for therapy services? If yes, what type (physical therapy, occupational therapy, aquatic therapy, therapeutic riding)? (a) Where would you like to receive therapy? i. Clinic/Facility Name and therapist: ii. Address: iii. Phone Number/email: (4) Are you applying for a grant for assistive technology/therapeutic equipment? If yes, what type? We apologize but we cannot help with adaptive vans at this point. (5) Have you applied for funding through another organization for the requested therapy services/ assistive technology/therapeutic equipment? If yes, what organization and please explain. (6) The JGL Foundation receives many requests each year for grants. It is our constant goal to increase our fundraising efforts so we may help all applicants. Please tell us how you might be able to support our organization in its efforts to grow and assist all applicants with Cerebral Palsy. Would you or your child be willing to tell your story (what challenges you/your child face(s) and why the requested grants would be helpful) on our website, pamphlets, and/or video? Would you be willing to volunteer or attend fundraising events? Could you write a letter of support? (7) Please tell us about yourself or child. (8) Please explain to us how you or your child will benefit from the requested therapy/assistive technology/therapeutic equipment. The following documents must accompany your application: If applying for funding for physical, occupational, or other therapy services, please provide the following: A letter of justification with a therapy plan (including short term and long term goals) from the treating therapist. An estimate from the therapist as to how many sessions are necessary to accomplish the short term goals in the therapy plan and an approximate cost. If applying for a piece of assistive technology or therapeutic equipment, please provide the following: A letter from your physical therapist/occupational therapist/physician stating how your mobility or your child’s mobility and/or functional ability will be enhanced by this particular piece of equipment. A quote from the vendor who will supply the necessary equipment or a picture and price of the equipment from therapeutic website/catalog.If you have questions regarding this application, please feel free to contact Jennifer Louie at firstname.lastname@example.org. Please note, we only perform a review of applications 3 times per year. We are a small organization; therefore many of our grants are partial grants for the requested amounts. Please also note, that if you or your child receive a grant we will only pay vendors/therapists for the equipment or services provided. We cannot issue the grant directly to the recipient. Once you have completed the application, you may email or mail the application and necessary documents. If you choose to email, please write COMPLETED APPLICATION in your subject heading. If you chose to mail, please send Jennifer an email to state that the application is in the mail. An application will not be considered complete until all documents are received. Thank you.