ADS Online Universal Grant Form

Our goal is to provide grants to those who might not have the means to access assistance to address their special needs

*Checks will be made out to provider and sent to you

*Upload proof of diagnosis (Doctor's note, OPWDD Statement, IEP cover page)

*Upload invoice for service

*Applications without sufficient information will not be considered until the packet is complete

Applicant's Name:
Applicant's Address:
Applicant's Phone Number:
Applicant's Email:
Program, service, or materials
for which you are applying:
Amount requested: $
Has applicant's insurance been billed: Yes
No
Check made payable to:
Proof of Diagnosis:
Invoice for service of materials: