Edwin Phillips Foundation
Application (via AANE)

I. Family Information

Mother's name _______________________________________________

Address ____________________________________________________

___________________________________________________________

Phone (day)______________________ (night)_______________________

E-mail ______________________Occupation _______________________

Father's Name ________________________________________________

Address (if different) ___________________________________________

___________________________________________________________

Phone (day)______________________ (night)_______________________

E-mail ______________________Occupation _______________________

II. Information about the Child

Name of Child with Disability _____________________________________

Date of Birth_____________________________ Grade in School _______

Name of School _______________________________________________

____ My child has been diagnosed with Asperger's Syndrome, HFA or PDD 
      (please include a copy of a letter or page of IEP indicating diagnosis)
____ My child is age 22 or under
____ My child lives at home
____ My child lives in Plymouth County

III. Request

Amount requested $__________

What will you use the funds for?

 

 

IV. Family Financial Information

Total taxed family income earned and unearned, before taxes $___________ 
        (please include a copy of page 1 and 2 of your tax return)

Are you receiving SSI for your child? ___ Yes ___ No

Have you received family support funds this year from any other agency? ___ Yes ___ No

If you have received family support funds, how much did you receive? $________? 
From which agency?

V. The Check

The check should be made out to: _____________________________________

The check should be sent to: _________________________________________

_______________________________________________________________

_______________________________________________________________

VI. Conflict of Interest/Agreement

I agree that the child does not have any relationship with the Phillips Foundation Trustees, Mr. Phillips or his family or any other contributor to the organization or any other corporation controlled by any other contributor to the organization.

I have read and completed this grant proposal and certify that the information contained in it is correct to the best of my knowledge and best of my belief. I certify that I have made a diligent search for other sources of funding for this request and that, to the best of my knowledge, there are no other resources, public or private, available to fulfill this request.

______________________________________ Date _________________________

Signature of parent or guardian

Please return this application to the Asperger's Association of New England, 182 Mian Street, Watertown, MA 02472 with:
____ First two pages of tax form
____ Document with diagnosis

The application will be processed within two weeks of receipt. Please call Dania Jekel at (617) 393-3824 if you have any questions.