Wounded Warrior Program Application Step 1 of 4 25% N-AbleTek Wounded Warrior 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 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 Main Contact Home Phone*Main Contact Mobile PhoneBest Time to Call Hours : Minutes AM PM AM/PM Main Contact Email (if different from above) Branch of MilitaryTHANK YOU FOR YOUR SERVICE!I am a Florida Wounded Warrior diagnosed with a traumatic brain injury (TBI) as a result of my military service.* Yes No I am employed.* Yes No I am seeking employment.* Yes No I have supporting documentation that can be used to identify whether cognitive-focused technology may benefit me in reaching my goals for 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/or language pathologist (SLP). 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 INCOME VERIFICATION MAY BE REQUESTED BY ONE OF THE FOLLOWING OPTIONS TO DETERMINE ELIGIBILITY: Proof of employment: If an adult household member is employed: two pay stubs from the last 60 days for each adult household member. Proof of enrollment in one of these programs: Supplemental Nutrition Assistance Program (SNAP): if your household is enrolled in SNAP, then submit proof of enrollment (e.g. documentation of enrollment for the current year). Free/Reduced Meal Program: If a child in your household is enrolled in the free/reduced meal program, then request documentation from your child’s school and submit to us to verify income eligibility. I live in a supervised setting away from my family and support myself.* Yes No I receive the majority of my financial support through Veteran’s Services.* 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 Participant, Parent, or other Legal Guardian signing*Signature of Participant, Parent, or other Legal Guardian signing*You have completed the Wounded Warrior section of the application. We will be contacting you soon.
