Special Needs Ability Program, Inc. PO Box 391438 Deltona, FL 32739 Telephone: (800) 816-5235 Fax: (386) 218-6443

Vacation Grant Application Getting Started… SNAP Vacation Grant Application: Please read the below information carefully then print out this Vacation Grant Application. Complete the application in Print to make sure contents are legible. Applications that cannot be read will result in application being returned to you without being processed. Once you’ve completed your application we are asking that you either mail in your application or scan it and submit it via email for faster processing to: [email protected] Please Note: Faxed Applications will not be accepted. Special Needs Ability Program’s Vacation Grant Program is a unique opportunity for families to experience a traditional family vacation that they may not otherwise be able to afford on their own. This program was developed, in part, by our partnering with Diamond Wishes Charity for Children who is generously sponsoring families to participate in Special Needs group vacations provided by Autism on the Seas (AOTS). First and foremost, all information obtained by Special Needs Ability Program, Inc. in qualifying each application, is held in the strictest of confidence. The information is not shared with any other organization or agency (including AOTS) under applicable state and federal law. Autism on the Seas is an organization that provides Special Needs Ability Program, Inc. the family group vacation options. They do not have any participation in the awarding of grants or knowledge of the actual amount of the award, until they receive funding from Special Needs Ability Program, Inc. Note: it is very rare for the Review Committee to award a greater amount than originally approved. See the “Grant Selection Process and Rules” section on our website under “Vacation Grant Program” for more information. For Special Needs Ability Program, Inc. use only:

Applicant Name: ___________________________________________________________________ Date Application Received: _______________ Date Application Fee Received:________________ Date Proof of Diagnosis Received:___________________ Date Proof of Income Received:____________________ Tracking No. Assigned: ______________ Staff Member Assisgned:_____________________________________________________________ 1|Page

Special Needs Ability Program Vacation Grant Application

What Happens After A Grant Is Awarded? 

When you are approved for a grant you will be notified via email of your grant award and the availability of funds for your desired cruise or land vacation. Should the funds be immediately available for your vacation choice, you’ll be given a date in which you must book your vacation with Autism on the Seas.

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After booking your vacation and placing your deposit, you’ll receive an invoice from Autism on the Seas showing your reservation number, desired vacation, and that you paid your required deposit. You are required to forward that invoice to us via email once you receive it. Once we receive your Autism on the Seas invoice your grant award will be funded within 48 hours. You will receive an invoice from Autism on the Seas showing the payment of your grant award has been paid in full.

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Deposits very depending on the cruise line you are selecting.

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o

Royal Caribbean charges between $200.00 & $500.00 per cabin

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Carnival and Disney charges $200.00 to $300.00 per person (deposit amounts subject to change, please check the Autism on the Seas website for your desired vacation for the applicable deposit)

Families may add extended family members to their Autism on the Seas booking at any time or select any desired cabin or room available. Any balance owed after the grant award is paid is the liability of the family’s. Should a family cancel their vacation prior to the final payment date, Special Needs Ability Program will be credited back the amount of their grant ward.

All grant applicants are subject to cruise or vacation availability and grant funds. Special Needs Ability Program does not award grants on any individual cruises offered by Autism on the Seas. Grant funds are earmarked to assist families to experience a once in a lifetime family vacation with the support of Autism on the Seas qualified staff to assist them.

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Special Needs Ability Program Vacation Grant Application

General Information Needed…

Please Initial:_________

Contact Person: Full Legal Name Number of persons cruising or vacationing Number of children or adults cruising with a disability: in your party: Your first cruise or vacation choice: Your second cruise or vacation choice: I have received financial assistance through Special Needs Ability Program in the past: I am a Business or Family Sponsor of Special Needs Ability Program, Inc. (not a requirement to apply for a grant) I have cruised/vacationed before with my Special Needs child/adult:

Yes

No If yes, when?

Yes

No If yes, your Sponsorship No.___________

Yes

No If yes, with AotS?

Let’s begin your easy online application… Primary Parent or Guardian: Date of Birth: Relationship to Special Needs child or adult: Home Mailing address:

Secondary Parent or Guardian: Date of Birth: Relationship to Special Needs child or adult:

Full Legal Name: Month: Day:

Year:

Street: City: Zip: Email address: Home phone: Cell: Full Legal Name: Month: Day: Year:

State:

NOTE: In the event the parent or guardian’s last name are different from their minor child(ren) the cruise line may require proof of custody or a notarized letter from the biological parent not traveling with you giving you consent to take the minor child(ren) on the cruise to a foreign country.

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Special Needs Ability Program Vacation Grant Application

About your Special Needs Child(ren)/Adults…

Please Initial:__________

#1 Full Legal Name: Diagnosis: #2 Full Legal Name: Diagnosis: #3 Full Legal Name: Diagnosis: #4 Full Legal Name: Diagnosis: #5 Full Legal Name: Diagnosis: #6 Full Legal Name: Diagnosis:

Date of Birth: Date of Birth: Date of Birth: Date of Birth: Date of Birth: Date of Birth:

About your typical children living in your home cruising with you… #1 Full Legal Name: #2 Full Legal Name: #3 Full Legal Name: #4 Full Legal Name:

Date of Birth: Date of Birth: Date of Birth: Date of Birth:

About your finances… Primary Parent or Guardian’s Employer: Occupation: Supervisor’s Name: Length of time in current position: I am a full-time employee: I am a part-time employee: I am a seasonal employee: I am unemployed: I currently receive SSI: I currently receive Unemployment: I currently receive Child Support: I currently receive Alimony: I am self employed: Annual Income: 4|Page

Annual Income: Telephone Number:

Yes Yes Yes Yes Amount $ Amount $ Amount $ Amount $

No No No No Per Month Per Month Per Month Per Month

Type of business: Note: Your most current Federal Income Tax return must be submitted for all self- employed grant applicants.

Special Needs Ability Program Vacation Grant Application

About your spouse, significant other, or other adult traveling with you… Please Initial:__________ Secondary Parent or Guardian’s Employer: Occupation: Supervisor’s Name: Length of time in current position: I am a full-time employee: I am a part-time employee: I am a seasonal employee: I am unemployed: I currently receive SSI: I currently receive Unemployment: I currently receive Child Support: I currently receive Alimony: I am self-employed: Annual Income:

Annual Income: Telephone Number:

Yes Yes Yes Yes Amount $ Amount $ Amount $ Amount $

No No No No Per Month Per Month Per Month Per Month

Type of business: Note: Your most current Federal Income Tax return must be submitted for all self- employed grant applicants.

Other Income… I/we receive state aid:

Food Stamps/Wick/EBT: Yes No If yes, amount: State Financial compensation: Yes No If yes, amount: Housing allowance/Section 8: Yes No If yes, amount: Childcare Allowance: Yes No If yes, amount: Respite or other social services: Yes No If yes, amount:

Monthly expenses… I/we own my/our home: I/we rent my/our home: I/we pay approximately $ I/we pay approximately $ I/we pay approximately $ I/we pay approximately $ I/we pay approximately $ I/we pay approximately $ I/we pay approximately $ I/we pay approximately $

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Monthly Mortgage Payment: $ Monthly Rental Payment: $ for food & household needs monthly. for gas, electric water & sewer. ( Please average 12 months) for automobile fuel monthly. for telephone, cable & cell phone monthly. for insurance, health, life, car, etc. monthly. for credit card debt monthly. for therapies not covered by state or school district monthly. for “other” monthly. Please explain:

Special Needs Ability Program Vacation Grant Application

About your vehicle(s)… Year

Make

Please Initial: _________ Model

Monthly Payment $ $

Application Fee… I hereby authorize Special Needs Ability Program, Inc. to charge my one-time nonrefundable application fee to my credit/debit card below. I understand that the application fee is not a guarantee of a grant being awarded to my family based on the information provided in my application. Name on Card:___________________________________________________________ Card Type:_________ Card Number:_______________________________________ Expiration Date:____________________ Security Code:__________ (Three digits located on the back of your card) Zip Code where you receive your credit card or bank statement:_________________ Application Fee: $25.00 Donation:

________

Total:

________ (Total amount you’re authorizing us to charge your card)

X_______________________________________________________ Date___________ Your Signature Authorizing the Charge

Note: You are welcome to securely pay your application fee on our website under Sponsorship/Donation. Please be sure to write in the Comment Section, your full name and “Grant Application Fee” for immediate credit.

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Special Needs Ability Program Vacation Grant Application

I, certify that all the information within this application is true and correct to the best of my ability. I understand that any fabrication of information will disqualify my application. My signature below authorizes Special Needs Ability Program, Inc. to screen and investigate my application for consideration of a grant award.

X______________________________________________________________________

Date Signed:____________________ Contact Number:_(

)___________________

Last steps… NO TE: For your application to be complete and be considered, we require the following information be mailed, emailed or faxed to us when submitting your application: 1. Proof of diagnoses for your child(ren). Proof can be offered by providing us with a current copy of your chid(ren) IEP, Letter from your Pediatrician, or copy of an assessment done within the last 12 months either privately or by school officials. 2. We will need a copy of the last pay stub for all qualifying adults living in the home or proof of Disability benefits. If current proof of income cannot be substantiated, we may request a copy of your last year’s Federal Income Tax return. 3. There is a one-time nonrefundable processing fee of $25.00 due upon receipt of this application. Application fee can be paid by credit/debit card , or by mailing in a check or money order made payable to: Special Needs Ability Program, Inc. with your completed application and mailed to: Special Needs Ability Program, Inc. PO Box 391438 Deltona, FL 32739 Please make reference to “Application Fee” in the memo section of your check or money order. Application will not be reviewed until all request information has been received. Additional information may be required and requested at any time upon request.

Special Needs Ability Program, Inc. grant program is funded, in part, through the generosity of our partnering sponsor.

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Special Needs Ability Program Vacation Grant Application