Equipment and Therapy Services Grant is sponsored by Variety, The Children's Charity of St. Louis. Variety St.

Louis provides financial assistance for durable medical equipment and/or therapy services for children with disabilities in the Greater St. Louis region.

Medical Equipment & Therapy Application - Variety St. Louis Medical Equipment & Therapy Application This application is for families of children with disabilities who are looking for financial assistance to access durable medical equipment and/or physical, occupational, speech, aqua or hippotherapy services for their child.

To receive assistance through these programs, you must demonstrate a level of financial need as well as present a prescription from a medical professional. Each case is reviewed on an individual basis. If you have already received Variety’s assistance in the past for equipment or therapy, please contact equipment@varietystl.

org or therapy@varietystl. org for separate instructions instead of completing this application. Gender (Required) gender Male Female Social Security No. (Required) Child’s Primary Diagnosis (Required) After receiving your application, Variety may request proof of diagnosis.

Parent/Guardian’s Information Primary Guardian(s) (Required) Relationship to child (Required) Parent/Guardian's Birthdate (Required) Primary Address (Required) State / Province / Region County (Required) Please select your county Crawford, MO Franklin, MO Gasconade, MO Iron, MO Jefferson, MO Lincoln, MO Perry, MO Pike, MO St. Charles, MO St. Francois, MO St.

Genevieve, MO St. Louis City, MO St. Louis County, MO Warren, MO Washington, MO Bond, IL Calhoun, IL Clay, IL Clinton, IL Fayette, IL Greene, IL Jersey, IL Macoupin, IL Madison, IL Marion, IL Monroe, IL Montgomery, IL Randolph, IL St.

Clair, IL Washington, IL *Your response to the following question is optional and will not affect the status of your application. The information requested is useful to St. Louis Variety in grant applications and other activities seeking additional funding for our assistance programs.

What is your child’s race/ethnicity race/ethnicity White Hispanic or Latino or Spanish origin American Indian or Alaskan Native Black or African American Middle Eastern or North African Some Other Race Asian Native Hawaiian or Pacific Islander Multi-Racial Variety is required to provide its funding partners with the status of program participants who receive funding through the Department of Mental Health waivers.

Does the child have a Missouri Department of Mental Health (DMH Regional Office) file? (Required) What is their DMH ID number? Please select if the Variety participant has any of these DMH Medicaid Waivers.

(Required) Partnership for Hope Waiver MOCDD (Sarah Lopez) Waiver No, the participant does not receive any of the above funding Is the participant enrolled in Medicaid? (Required) Nature of Request (Required) Both Equipment and Therapy Please provide detail on the type of equipment or therapy you are seeking. (Orthopedic Equipment, Wheelchair, Therapy, Etc.) (Required) Are you currently working with an equipment company or therapist?

(Required) What is the name of the equipment company or therapy provider? (Required) Have you received financial assistance for adaptive equipment from another charity within the past 12 months? (Required) Name of the charity/charities?

(Required) When did you receive this assistance? (Required) Household Income Information Number of earners in the household (Required) Number of members in the household (Required) Earner #1’s income per Year (Required) Current Employer (Required) This field is hidden when viewing the form State / Province / Region This field is hidden when viewing the form How long have you been employed by this employer?

Earner #2’s income per Year (Required) Current Employer (Required) This field is hidden when viewing the form State / Province / Region This field is hidden when viewing the form How long have you been employed by this employer? Describe any extraordinary expenses or special circumstances. Be specific as to the expense and anticipated duration of the circumstances.

Please upload the first page of the most recent federal income tax return (Form 1040). This page should include Adjusted Gross Income and a list of dependents. If your household does NOT file taxes, but does receive SSI, please upload the most recent copy of the SSI Award letter.

You may choose to provide these documents later, but they are required to determine eligibility. Most Recent Federal Income Tax Return Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

This field is hidden when viewing the form This field is hidden when viewing the form Calculate your Monthly Income & Expenses Variety prioritizes equipment and therapy requests from families with an Adjusted Gross Income of less than $85,000. Variety will consider requests from households with higher income on an individual basis.

To be considered by Variety’s Review Team, please calculate and provide your monthly financial information below.

This field is hidden when viewing the form Earners #1 Monthly Income This field is hidden when viewing the form Earners #2 Monthly Income This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form Special dietary food/supplements This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form Child support paid/alimony paid This field is hidden when viewing the form Car loans/public transportation costs This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form Health insurance (plan and HSA) This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form Donations/charitable giving This field is hidden when viewing the form This field is hidden when viewing the form Extracurricular activities This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form (haircuts/toiletries/ gifts/etc.) This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form Primary Care Physician and/or Therapist This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific This field is hidden when viewing the form Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific This field is hidden when viewing the form This field is hidden when viewing the form School District Child Attends This field is hidden when viewing the form Names & Ages of Additional Children Residing in the Household This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form This field is hidden when viewing the form How did you hear about Variety?

The funding of equipment/therapy would not be possible without many individuals, companies, and foundations within the Greater St. Louis community who contribute to Variety. Our programs depend on these benefactors.

With that in mind, you will be required to complete a survey to report how your child’s piece of equipment/therapy has impacted his/her life, and that of your family. Your responses will be critical to increasing funding for Variety programs. Consent (Required) I acknowledge that I will be required to complete a survey if I am provided equipment / therapy.

(Required) The life of a parent of a special needs child is always changing and Variety has really shown us that you all are in this with us Sarah, Variety Kid Will’s Mom