Developmental Disability Program Application Developmental Disability Program Application Step 1 of 4 25% N-AbleTek Developmental Disability Program ApplicationN-AbleTek seeks to provide cognitive-focused technology to Floridians with developmental disabilities or wounded warriors with traumatic brain injury. In order to support as many people as possible, we want to be sure that we are providing the resources to individuals who may not be able to afford to purchase themselves. We will use this application process to make a determination of eligibility. The information you provide us below will help us determine whether you are eligible for software, software and hardware, or training assistance only in the download, install and use of self-purchased software applications. A final determination may require an interview with the responsible party seeking participation and/or a member of their support team.How did you hear about this program?* Website Friend School/Teacher Healthcare Member/Therapist Job Coach Information Fair Participant Name* First Middle Last Name of Guardian/Responsible Party* First Last Phone of Guardian/Responsible Party*Email of Guardian/Responsible Party* Participant's Date of Birth MM slash DD slash YYYY Participant's Age*Please enter a number from 1 to 99.Participant's Gender* Male Female Participant's Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Participant's school attendedMain Contact Home Phone*Main Contact Mobile PhoneBest Time to Call Hours : Minutes AM PM AM/PM Main Contact Email* EligibilityPlease answer the series of statements to help us determine if you are eligible to participate in the program.Florida Statutes, Chapter 393 defines developmental disabilities as individuals with: Autism Cerebral palsy Spina bifida Intellectual disabilities Down syndrome Prader-Willi syndrome Phelan McDermid syndrome Children aged 3-5 who are at a high risk of a developmental disability I am a Florida resident diagnosed with a developmental disability as defined by the State of Florida above.* Yes No I am registered through the State of Florida to receive developmental disability services.* Yes No I have supporting documentation that can be used to identify whether cognitive-focused technology may benefit me in reaching my goals for communication, completing tasks of daily living and similarly related activities. This may include documentation from your current licensed physician/nurse practitioner, occupational therapist, job coach, speech and language pathologist (SLP), and/or teacher.* Yes No I live in the following County:* Charlotte Collier Hillsborough Lee Manatee Pinellas Sarasota I live with and I am financially supported by my family.* Yes No Does my household income exceed:* $86,000 for 2 household members $108,500 for 3 household members $131,000 for 4 household members $153,500 for 5 household members $175,500 for 6 household members $198,200 for 7 household members $220,500 for 8 household members I live in a supervised setting away from my family and with a service provider.* Yes No I receive the majority of my financial support through State Program related funding.* Yes No I am on a waiting list to receive developmental disability funding.* Yes No What do you think?Help us understand why you believe that this equipment will make a difference in your daily life! We would love to know what you hope to accomplish with this equipment.Why do you feel it is needed? How will this promote and enable personal growth and independence for you?* MiscellaneousAffirmation of Truth:I(WE) stipulate that the information included in this application is true to the best of my (our) knowledge. Further I (we) understand that the presence of inaccurate information in the application could result in the need for the re-evaluation of this application on the part of N-AbleTek. N-AbleTek, Inc. reserves the right to terminate participation in the program. Destruction/damage to equipment may justify dismissal from the program. Due to available funds, not all applicants may be accepted into the program but may reapply in the future. Signature I have read and fully understand the above information:Name of Client, Parent, or other Legal Guardian signing*Signature of Client, Parent, or other Legal Guardian signing*You have completed the Developmental Disability section of the application. We will be contacting you soon.
