Mother's Address:

Name of the Facility's Director: *

Legal Guardian's Email:

Child's Address:

How many hours per day does child need additional support? *

Legal Guardian's Place of Employment:

Child's Date of Birth:

Mother's Place of Employment:

Name of Facility: *

Name of Staff Completing the Application: *

Facility Website: *

Father's Phone:

How long would you need funding for? *

Mother's Name:

Mother's Email:

Father's Name:

Father's Place of Employment:

Father's Email:

Facility Phone Number: *

I have received permission to share personal information from the parents of the child discussed below on for the purposes of applying for this grant. *

Yes

Legal Guardian's Address:

Facility Assistance Grant Application

Please complete if you are requesting financial support to hire additional one-on-one personal staff, equipment, or training which will increase a child’s safe participation within your setting.

This financial support will allow your facility to continue to provide safe and quality care to a child with additional behavioral, physical or medical needs.

Before completing this application, please discuss your intention of applying with the child’s parent and get permission to release their name and information as part of the application.

Mother's Phone:

What challenges does the child present which indicate more adult intervention is necessary than that of his/her peers? *

Child's Name: IMPORTANT! Please complete this portion ONLY AFTER your facility has obtained a guardian signed release of information.

Address of Facility: *

Father's Address:

How will this funding increase your ability to provide continued care for the child? *

Father's County of Residence:

Legal Guardian's Phone:

Legal Guardian's County of Residence:

Once your application has been processed, you will be contacted within one week by the PVHM Foundation.

If your situation is urgent or time sensitive, please feel free to reach out to Joyce at: JoyceL@pvhfoundation.org or (920)850-3409

Empowering parents of children with disabilities to re-enter and remain in the workforce.

Legal Guardian's Name:

When would you need funding to begin *

Mother's County of Residence:

Are his/her additional needs putting him/her or his/her peers at risk? Is safety at any time, with any children or staff being compromised? If so, please explain. *