Adaptive Equipment Application

Before beginning the application, please read the following:

The application cannot be saved in the middle. Once begun, it must be completed in order for The Arya Foundation to receive it. The fields marked * are mandatory.
Make sure you know the email and phone number of the referral contact.

After submitting this application, please submit the remaining required documents by email or mail.

If you have any questions, please contact us by clicking the button below.

Child's Information

Child's Name

First Name

Last Name

Birth Date

YYYY

Qualifying Medical Condition

Permanent Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County

Family Information

Child's Siblings Names & Ages

Type N/A if none

Parent/Legal Guardian 1

First Name

Last Name

Email Address-1

Phone Number-1

(###)

###

####

Parent/Legal Guardian 2

First Name

Last Name

Email Address-2

Phone Number-2

(###)

###

####

Medical Information

Healthcare professional associated with current care

Physician Name

First Name

Last Name

Child's Clinical Diagnosis

History of Illness/Health Condition

Adaptive Equipment

Type of Equipment

URL of Adaptive Equipment

http://

Cost of Equipment

Requested Funding Assistance

If cost of equipment is more than $1000, how will the remaining funds be paid

Type N/A if cost of adaptive equipment is less than $1000

Missouri Children with Developmental Disabilities Waiver a.k.a Sarah Lopez Waiver

Does your child have a Missouri Children with Developmental Disabilities Waiver a.k.a. Sarah Lopez Waiver?

If yes, please email or mail the adaptive equipment denial letter to The Arya Foundation at info@TheAryaFoundation.org or P.O. Box 4443, Chesterfield, MO 63006

Referral

Person Referring

First Name

Last Name

Organization

Email Address-3

Phone Number-3

(###)

###

####

Affirmation and Consent

In order for The Arya Foundation, a non-profit organization, to advance financial assistance for the purchase of adaptive supplies or equipment’s, the undersigned do hereby affirm as follows: 1.The undersigned are the parents or guardians of the child. 2.The undersigned further agree(s) to return any unused funds immediately to The Arya Foundation so that those funds can be utilized by the organization to benefit other families. The Arya Foundation reserves the right to distribute funds at its sole discretion. The Arya Foundation may pursue restitution for grants if it is determined that the information submitted on the application is false. I have read the guidelines for financial assistance and I declare that the information furnished on this application form is true and correct to the best of my knowledge. I am 21 years of age or older and have read and understand the above statements.

First Name

Last Name

Signature of Parent/Legal Guardian

By entering your name below, you agree that the electronic printing of your name shall have the same force and effect as a written signature

Date

YYYY

Equipment Application

Adaptive Equipment Application

Contact