GIVE THE GIFT OF VOICE
HOLIDAY GIVING CAMPAIGN
2010 APPLICATION
Please completely review the following information before filling out this application.
Applications will be reviewed in the order they are received. Donations for the 2010 Holiday Giving
Campaign will be accepted through midnight December 31st, 2010. At that time, it will be determined
how many iPads HollyRod Foundation is able to purchase. iPads will be given to verified applicants in
the order in which they were received.
This program is intended only for individuals on the autism spectrum that are non-verbal or minimally verbal and.
Frequently Asked Questions
Q: What are the eligibility requirements??
A: You must meet the following criteria to apply:
1. The individual you are applying for must have a diagnosis on the autism spectrum (as identified in diagnosis report).
2. Reside in the United States of America.
3. Be non-verbal or minimally verbal (as identified in speech pathology report).
4. Be in financial need: Gross income not to exceed $35,000 single income family or $50,000 two-income family (as
identified by documentation).
5. Have access to a computer and an iTunes account (some programs must be downloaded on a computer and transferred
to the iPad due to size).
6. A professional on your team (i.e., speech pathologist, doctor, teacher) must be willing to take responsibility of the gift
card that downloads the applications.
Q: Is there an age limit for who I may apply for?
A: No. As long as the individual to receive the iPad meets the above criteria, they can be any age.
Q: How will you verify information on submitted applications?
A: HollyRod Foundation will call providers stated on application and in submitted reports to verify information. By signing
application you give HollyRod Foundation permission to contact stated providers.
Q: How do I apply for the iPad?
A: If you meet the eligibility requirements stated above, complete the HOLIDAY GIVING APPLICATION. You must attach
some form of documentation that confirms your child's diagnosis, verbal abilities (i.e., diagnosis report, speech report, school
eval, etc) and financial need. If you have multiple children with autism, you must attach each child’s paperwork if requesting
more than one unit.
Q: Will I get my iPad fully loaded?
A: Since apps will need to be updated, you will have to load the iPad through your own iTunes account. To ensure legitimacy of
who receives the iPads, we will ask your provider (Speech, teacher) to take responsibility of a gift card that will allow purchase
of specific apps.
Q: I've sent my application in. How long until I know if my application has been approved?
A: Once we have received all components of the application (completed application form, doctor's letter, financial
documentation, provider statement), your application will be reviewed by the HollyRod Foundation staff. After all aspects of application have been verified, application will be assigned a number in the order it was received. Based on total donations received by 11:59pm PST, December 31, 2010, HollyRod Foundation will determine the number of iPads it can purchase. iPads will be given away according to order of applications until all iPads have been disbursed. ONLY RECIPIENTS RECEIVING AN iPAD WILL BE CONTACTED. Recipients will be contacted in January 2011.
Q: I have health insurance. Can I still apply for assistance?
A: Yes. As long as your family’s gross income does not exceed $50,000 and insurance will not pay for a communication device,
you are eligible to apply for your loved one.
HollyRod Foundation 2010 Holiday Giving Campaign 2
CHILD
Name: ______________________________ Age:_______ Date of Birth: ____________
MOTHER
Mother’s Name:______________________________________________________________
Marital Status: _______________ Telephone: _____________________
E-mail Address:_______________________________________________________________
Street/City/Zip:_______________________________________________________________
Employer:_____________________________ Telephone: ___________________________
Employer Address:____________________________________________________________
FATHER
Father’s Name:_______________________________________________________________
Marital Status: _______________ Telephone: _____________________
E-mail Address:_______________________________________________________________
Street/City/Zip:_______________________________________________________________
Employer:_____________________________ Telephone: ___________________________
Employer Address:____________________________________________________________
Number and ages of other dependent children:__________________________________
___________________________________________________________________________
Diagnosis of Disability: ______________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Name of diagnosing doctor: __________________________________________________
E-mail Address:______________________________ Phone:___________________________
Street/City/Zip:_______________________________________________________________
HollyRod Foundation 2010 Holiday Giving Campaign
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Outline of child’s communication challenges:
___________________________________________________________________________
___________________________________________________________________________
________________________________________________________________________________
Name of Speech Pathologist: __________________________________________________
Practice or school Name: _______________________________________________________
E-mail Address:______________________________ Phone:___________________________
Street/City/Zip:______________________________________________________________
SUPPLEMENTAL SECURITY INCOME (SSI) $_________
Personal Statement of Income and Financial Status of Custodial Parents or Guardians
ASSETS LIABILITIES
Checking Account $____________ Monthly House Payment/Rent $____________
Savings Account $____________ Other Monthly Bills/Loans $____________
Real Estate $____________ Monthly Utilities $____________
Home Value $____________ Monthly Insurance $____________
Automobiles $____________ Monthly Automobile Expenses $____________
Personal Property $____________ Medical Bills Due $____________
Other Assets $____________ Physician/Agency $____________
Total Assets: $___________ Total Liabilities: $___________
Combined sources of income:
Previous year's IRS return must be attached if grant request is above $300.00.
INCOME TYPE MONTHLY ANNUAL
Salary: $___________ $___________
Bonuses and Commissions: $___________ $___________
Alimony/Child Support: $___________ $___________
Real Estate Income: $___________ $___________
All Other Income: $___________ $___________
TOTAL INCOME: $___________ $___________
(ALL OTHER INCOME is including Grants, Social Security, CRS, Medicaid, etc.)
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HollyRod Foundation 2010 Holiday Giving Campaign
The above information is freely given to process this application request. By signing, I attest that all
information included is true and accurate and give HollyRod Foundation permission to contact my
child’s medical professionals listed to verify and discuss diagnosis and speech abilities. I understand
that falsifying information will immediately disqualify this application.
I understand that the iPad is to be used solely as a communication device for the child applied for. I
confirm that the family I am helping understands and agrees to abide by these rules.
PARENT/GUARDIAN SIGNATURE:__________________________ DATE:___________
Mail completed application, documentation confirming child’s diagnosis (i.e., school eval, or
doctor’s note), speech abilities, previous year’s IRS return and Provider Statement to:
HollyRod Foundation c/o “2010 Holiday Campaign”
9250 Wilshire Blvd., Suite LL15
Beverly Hills, CA 90212
This application cannot be considered until this form is completed, signed, and all supporting
documents are received. The information included in this application is confidential and for HollyRod
Foundation use only. Please keep a copy for your records.