Autism Fund Application

Our goal is to provide local families with resources, tools, education & support groups. LAF is dedicated to help find a cure for autism. LAF realizes that many families with autism are not only faced with the emotional strain of dealing with a child’s medical needs, but there is also a major financial strain. We understand firsthand that there are not a lot of community services or programs available to families. Therefore, our goal is to set aside some of the funds raised to support local families with transportation, devices, programs that will directly benefit the child.

How will LAF funds be used:

  • 100% of the funds raised will stay locally. Funds are not sent to any national autism organization.
  • LAF will provide help for all children, teens and adults on the spectrum.

For further information please email info@laxautism.org. To apply for funds online, please fill out and submit the form below. Or, you can download the application, fill it out and either email it to info@laxautism.org or mail it to:

LA CROSSE AREA AUTISM FOUNDATION
317 4th St South #297
La Crosse, WI 54601

Download LAF Funds Application

Autism Fund Online Application

Background Information
Date

Applicant’s Name

Date of Birth

Parent/Legal Guardian

Address

City, State, Zip

County

Email

Home Phone

Cell Phone

Primary Diagnosis

Secondary Diagnosis

Referral Person

Physician’s Name and Hospital

Child’s Condition (check one)
1.Personal Care Assistance
Unable to help themselvesSome assistance neededNo assistance needed

2. Mobility limitations
Cannot walkAssistance walkingNo assistance needed

3. Verbal limitations
Non-verbalVery limited verbal skillsFully verbal

4. Cognitive abilities
Severe developmental delaysHas moderate delaysHas mild delays

5. Behavioral challenges
Presents significant behavioral challengesPresents minor behavioral challengesPresents no behavioral challenges

6. Safety concerns
yesno
Explain

7. Significant medical needs
yesno
Explain

Financial Information
Annual Gross Family Income

Place of employment
Mother

Father

Other sources of income (examples: child support, maintenance, trust funds, legal settlements or monies in any other special fund)

Number of persons in the family (including applicant)

Does the applicant and parent/legal guardian have private insurance?
yesno

Please list all state and/or federal assistance and amounts available to the applicant and parent/legal guardian (i.e. Badgercare/SSI)

Has the applicant enrolled in any County services and/or waivers? If so, list waiver/service and estimated date of redemption

Type of Support Requested
Type of support requested

(All grant applications require a letter of support from a medical provider or licensed clinician. Estimates and quotes are required for any equipment requests. iPad requests require a letter of support from an educational representative and a written plan from the school on how the iPad will be used to assist. LAF does not fund services or purchases that have already taken place.)

Amount of funding requested

How much of your personal funds are you able to provide towards this request?

What amount of money from support services will be contributed towards this request?

When are the funds needed? (Please allow 30-45 days for processing)

Have you applied to LAF before?
yesno

If yes, how much have you previously applied for and what was the actual amount received?

What were the funds used for?

Participation/Volunteering Opportunities
We at LAF are always trying to raise awareness, understanding and acceptance of those with Autism Spectrum Disorders. One avenue to help us accomplish this goal and promote our organization is to have families come and share their stories at our events.

Would you be interested in sharing your story at a LAF event?

Would you ever be interested in volunteering for a LAF event?
yesno

If yes, do you prefer
weekdaysweeknightsweekends

Photo and Media Consent
In order to help us raise the funds that we need to support our mission and goals, we like to share images of families that we have helped in various ways within our community.

Would you be willing to email or mail in photos of the applicant using the product or service requested?
yesno

Please send the images in via our email address or mailing address provided in the waiver section. These images would potentially be used for our marketing pieces, website use or sharing with donors. Please specify who is in the image, what is happening in the photo, item/service funded by LAF.)

By signing below, I agree to let the La Crosse Area Autism Foundation utilize my image for any marketing, social media, interviews, general media or website usage. This authorization is valid unless revoked in writing by person signing this form.

Digital Signature (please write full name and date)

Waiver for Application

Applicant, Co-Applicant and/or Guarantor (if applicable) agree to release and indemnify the La Crosse Area Autism Foundation or LAF from all liability arising from (1) LAF’s access to or disclosure of information under this application, (2) Applicant and/or Co-Applicant submitted information disclosed on this application, and (3) any other violations of the applicable laws due to the acts or missions of LAF. Further, Applicant and Co-Applicant agree to release and indemnify LAF’s information suppliers, their affiliate entities, as well as their officers, employees, contractors, donors and agents from all liability pursuant to this agreement.

Any application submitted to LAF or any fund commitment issued by LAF is submitted or issued, as the case may be, in contemplation of LAF assisting in the Applicant’s journey and adaption to their issues related to an ASD (Autism Spectrum Disorder) and for no other purpose. IN the event any applicant fails to pursue an application or otherwise ceases to use LAF’s services or an applicant’s application is denied, or in the event LAF issues its commitment and the transaction for whatever reason fails to close, then neither the applicant nor any other party shall have any cause of action or recourse against LAF, its officers, employees, directors, participants or affiliates based on the application or commitment. By submitting an application, or seeking financial assistance or consulting services or by accepting a disbursement of funds, the applicant, along with any other parties to the contemplated transaction, consents to and agrees with the foregoing. In addition, any good or services to an applicant shall not be or be deemed to be a representation or warranty of the competence , timeliness or integrity of such vendor, supplier or contractor, and LAF shall have no liability to any applicant or potential applicant for any problems arising from the use of such vendor, supplier or contractor.

Applicant and/or Representative signature acknowledging aforementioned waiver (please write full name and date)

Person signing is
applicantparent/legal guardian

To complete your application, please upload the following:

A letter explaining the diagnosis of applicant

A letter of recommendation from a professional who works with the applicant

REMINDER: FILLING OUT AN APPLICATION IS NOT A GUARANTEE OF FUNDING. PLEASE ALLOW 30-45 DAYS FOR PROCESSING. YOU WILL BE CONTACTED WITH AN APPROVAL OR DENIAL BY OUR OFFICE.