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Application for Assistance

Requirements:
You must meet the following requirements before submitting an application.

1) Child is age below 18
2) Request qualifies as a valid health need
3) Child lives in St Louis and surrounding area
4) Referred by a Social Worker or Case Manager or Therapist, etc.
5) Request is for up to $1000

Document Checklist:
Submit below documents for faster processing of the request

1) Complete Application form
2) Letter from a physician (on letterhead) providing the necessity of the equipment including the child’s diagnosis, history of illness, specific request for funding and other
relevant information
3) Invoice from the provider
4) Child’s photo and story
5) Consent for publication
6) Missouri Children with Developmental Disabilities Waiver (MOCDD) a.k.a. Sarah Lopez Waiver denial letter. (If child has granted this waiver.)

Contact Information:
For questions regarding your application or The Arya Foundation, please contact us at :

 The Arya Foundation
P.O. Box 4443
Chesterfield MO 63017

Phone: 314 445 ARYA (2792)
info@TheAryaFoundation.org
www.TheAryaFoundation.org

Application Form

Child's Information
Child's Name *
Child's Name
Birth Date *
Birth Date
Permanent Address *
Permanent Address
Current Address
Current Address
If different from the Permanent Address
Family Information
Parent/Legal Guardian Name 1 *
Parent/Legal Guardian Name 1
Relationship *
Mailing Address *
Mailing Address
Home Telephone Number
Home Telephone Number
Cellular / Work Telephone
Cellular / Work Telephone
Parent / Guardian Name 2
Parent / Guardian Name 2
Relationship
Mailing Address
Mailing Address
Home Telephone Number
Home Telephone Number
Cellular / Work Telephone
Cellular / Work Telephone
Enter N/A if none
Medical Information
Physician's Name *
Physician's Name
Equipment Request
$
$
Enter N/A if cost of item is less than $1000
Provider Address *
Provider Address
Referral (Organization, Social Worker, Case Manager, Therapist etc.)
Referred Person's Phone
Referred Person's Phone

Affirmation and Consent

In order for The Arya Foundation, a non-profit organization, to advance financial assistance for the purchase of medical 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, including attached sheets, is true and correct to the best of my knowledge. Please refer to the checklist at the top of page one of the application and attach all required documents prior to submitting the application.

I am 21 years of age or older, and have read and understand the above statements.

Child's Name *
Child's Name
Parent / Guardian Name 1 *
Parent / Guardian Name 1
Confirm Parent / Guardian Name 1 *
Confirm Parent / Guardian Name 1
This serves as your electronic signature that you have read and consented to the statement above
Signature Date *
Signature Date
Parent / Guardian Name 2
Parent / Guardian Name 2
Confirm Parent / Guardian Name 2
Confirm Parent / Guardian Name 2
This serves as your electronic signature that you have read and consented to the statement above
Signature Date
Signature Date