Family Grants Application Form

All required fields are marked with an asterisk (*).

I. Program Selection

I live in Plymouth County and am applying for a grant from the Edwin Phillips Foundation.
I do not live in Plymouth County, but do live in New England, and am applying for a grant from the Doug Flutie, Jr. Foundation or the AANE Family Grants Program.

II. Your E-Mail Address

Your email:

III. Family Information

Mother's Name
Address
Phone (Day)
Phone (Evening)
E-mail Address
Occupation
Father's Name
Address (If different)
Phone (Day)
Phone (Evening)
E-mail Address
Occupation

IV. Information about the Child

Name of Child with Disability
Date of Birth
Grade in School

This section below is required. Please check at least one box.

My child has been diagnosed with Asperger Syndrome or HFA (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

V. Request

* Amount Requested:

* What will you use the funds for?


VI. Family Financial Information

* Total taxed family income earned and unearned, before taxes (please send us a copy of page 1 of your latest 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?

VII. The Check

* The check should be made out to:

* The check should be sent to:


VIII. Conflict of Interest / Agreement

I agree that the child does not have any relationship with the organization (the Doug Flutie, Jr. Foundation Trustees, the Flutie family, OR 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.

* Please check here if you agree to these terms.

IX. Additional Materials Required

Please mail or fax the following information:

  • First page of tax form (or documentation from SSI, SSDI, or Transitional Assistance if you are not required to file a tax return)
  • Official document with child’s diagnosis

Mailing Address:

Asperger's Association of New England (AANE)
85 Main St.
Suite 101
Watertown, MA 02472

Fax: (617) 393-3827