Personal Equipment Application

Feel free to fill out the online form, or download and print the application by clicking the button below

Personal Equipment Request Application

It is our mission to improve the quality of life for children with multiple disabilities or profound deafness by providing needed adaptive equipment and select services. Incomplete applications will not be considered and returned to applicant for completion. Please note that at this time Be An Angel is unable to provide support for surgical procedures, ongoing therapies, or purchase of vehicles.

Name of Disabled Child*
First Last
Age of Child*
Child's D.O.B*
MM
DD
YYYY
Gender (select one)*
- Male
- Female
Child's Disabilities (List all medical diagnoses)*
Name of Parent/Legal Guardian*
First Last
Home Phone
Cell Phone
Work Phone
Address*
Street Address Address Line 2 City State ZIP Code
Name of County
Email
Name of Child's Current School*
School District*
Name of Child's Therapist
Prefix First Last
Therapist's Phone Number
Name of Child's Medical Doctor*
First Last
Medical Doctor's Phone Number*
Please list any additional medical professionals involved (If applicable)
Why should Be An angel assist you at this time? (i.e.: job loss, medical bills, etc.)*
How will this assistance benefit your child and your family?
What type of assistance are you requesting? (Check all that apply)*
- Wheelchair
- Medical Stroller
- Camp (online registrations only at www.BeAnAngelCamp.org)
- Adaptive Trike
- Van Lift/Ramp Conversion (Please submit copy of title or bill of sale, make, model, and mileage of vehicle)
Please provide a current vender quote or fact sheet including purchase price for each piece of equipment requested*
THIS QUOTE IS REQUIRED
Drop files here or
Have you applied for assistance from us before?*
If yes, when?
Have you received assistance from us before?*
If yes, when?
Please list other community agencies, doctors, and foundations that you have contacted about your current need. Provide addresses and/or phone numbers.
Please attach any denial letters you have received. (If applicable)
Drop files here or
Please list all household members, INCLUDING THE DISABLED CHILD*
Click the plus icon to add additional household members
Full Name Date of Birth Relationship to Child
Household Resources
All of the following information must be included in order to receive assistance
Net Employment Income (Take Home Pay)
$/Per Month
Unemployment Income
$/Per Month
Child Support
$/Per Month
Social Security
$/Per Month
Food Stamps
$/Per Month
Savings
$/Per Month
Housing Assistance
$/Per Month
Other Income (if applicable)
$/Per Month
Average Total Monthly Income:
Household Expenses
All of the following information must be included in order to receive assistance
Home Insurance
$/Per Month
Mortgage/Rent
$/Per Month
Electricity
$/Per Month
Gas
$/Per Month
Water/Sewer
$/Per Month
Home Phone/Internet
$/Per Month
Cell Phone
$/Per Month
Cable/Satellite TV
$/Per Month
Health Insurance/Medical Bills/Prescriptions
$/Per Month
Car Payment
$/Per Month
Car Insurance
$/Per Month
Child Care
$/Per Month
Average Food Expense (Groceries/Eating Out)
$/Per Month
Other Expenses
$/Per Month
Average Total Monthly Expenses
Please attach all CURRENT (previous month is preferred) income and expenses supporting documents*
(i.e. W2 or payroll stub, lease agreement, electric bill, phone bill, insurance payment, etc.)
Drop files here or
Have you made this request to Medicaid or to your primary insurance carrier?*
All information provided on this form is true and correct to the best of my knowledge.
In agreement of this statement please provide your full name below, along with the date of signature.
Electronic Signature of Parent/Legal Gaurdian*
Full Name
Date*
Authorization for Release of Information
Refusal to provide necessary documentation or to answer an interviewer’s questions will disqualify me and my household from assistance. Any false or misleading information provided in writing or verbally will disqualify me and my household from assistance. I certify that all information provided to Be An Angel either in writing or verbally is correct and true to the best of my knowledge. Additionally; I give permission for Be An Angel staff to verify information by contacting any party I have listed or verbally mentioned in the process of seeking assistance. Any discrepancies between my application information and verification efforts will be provided to me for clarification. I release Be AN Angel from any liability or legal responsibility that may arise from the verification process.
Child's Name*
First Last
Electronic Signature of Parent/Guardian*
Full Name
Date*
OPTIONAL: Media Release
I give Be An Angel FUnd, Inc. the right to interview and/or take photographs, audio or visual-recordings of me/my child to be sued in promotional, education, or fundraising materials including, but not limited to videotapes, pamphlets, and brochures. I understand my/my child's name may be used in connection with these materials. By signing this media release, I intend to legally bind myself, my minor children, my heirs, executors, and administrators. I acknowledge that Be An Angel Fund, Inc. shall have all rights of copyright in and to such photographs and videotapes and may use such copyright fully. I also hereby release Be An Angel Fund, Inc. and its officers, agents, and employees from all liability connected with the taking and use of these materials as is authorized by Be An Angel Fund, Inc. In addition, I waive all rights, interest, or claims from payment in connection with any exhibition or release of these materials. This consent is voluntary, and I give it in the interest of public information, education, and the furtherance of the goals of Be An Angel Fund, Inc. or other lawful purposes. I acknowledge that I have the legal authority to sign this form on behalf of the minor child whose name is mentioned above.
Electronic Signature of Parent/Guardian*
Full Name *OPTIONAL*
Date*
Client's Rights
Clients have a right to all of the services of the agency they qualify for (as long as they follow the guidelines). The services will be provided in the most efficient manner that meets the client’s needs. Each client has the following basic rights: 1. A right to respect, consideration, and safety 2. A right to make his/her own life decisions 3. A right to privacy and confidentiality in personal matters 4. A right to discontinue services with Be An Angel at any time 5. A right to any information kept by Be An Angel about him/her, and may review personal records upon request, by established procedures. Each client may record entries in his/her file. Each client has the following rights in regard to services available: 1. A right to have services available posted for easy access to view them, and to a copy of the description of services. 2. A right at the time of intake to have guidelines explained and to sign understanding and consent to follow these guidelines, and to a copy of the guidelines. 3. A right to be informed of Client Grievance Resolution Procedures and to a copy of these procedures.
Client Grievances Resolution
Any client who has a complaint, problem, question, or grievance should immediately bring it to the attention of the program direct.r The parties are encouraged to resolve the problem in the most direct fashion, at the most immediate level and in the least complicated manner. However, if a satisfactory resolution is not received at that level, the client should then promptly take the matter to the next level as follows: 1. Executive Director 2. Be An Angel Board Grievance Committee If the matter is not resolved at the Executive Director’s level, the client should present his/her problem, grievance or complaint, in writing, to the Board Grievance Committee, 2003 Aldine Bender, Houston, Texas 77032. The Committee will investigate the complaint and recommend possible solutions. There is no standing meeting time; the Committee meets on an as-needed basis. A written decision by the Committee may be expected not more than fourteen (14) days from receipt of the written complaint unless otherwise notified in writing by the Committee. The client must include a current mailing address and phone number on all correspondence. No decisions will be made or reported via telephone. The decision of the Board Grievance Committee shall be final.
Agreement*
I have read and understand the above statements regarding my rights as a client.
Electronic Signature of Parent/Legal Gaurdian*
My signature verifies that the information I have provided the agency is true to the best of my knowledge and may be used to determine my eligibility for the services offered at this agency. Further, I understand that my receiving assistance at this agency is determined by cooperating with the agency staff and fulfilling my responsibilities and obligations.
Date*
Hold Harmless Agreement
Whereby I agree, that should I receive goods and/or services from Be An Angel Fund, Inc. (BAA) as a result of this assistance request, I do so entirely of my own initiative, risk, and responsibility. Therefore, in consideration of BAA approving my request and providing requested goods and/or services I do hereby, for myself, all those on behalf of whom I may have made the request, my or their heirs, executors and assigns, release and forever discharge BAA and any of tis affiliates, or subsidiaries and all of its officers, agents and employees, acting officially or otherwise, and any school district from any and all claims, demands, actions or causes of action on account of my death, or any injury to me or to those on behalf of whom I may have made the request, or my personal property, which may occur from any cause, including negligence of any type. Therefore, netierh BAA nor its affiliates or subordinates, officers, agents, and employees, nor any school district shall be or become liable or responsible for any loss, injury, or damage to any person, property, or otherwise in connection with any good and/or service resulting directly or indirectly from any defect in or misapplication of said goods and/or service including any breakdown in machinery or equipment, or for any loss or damage resulting from defective equipment, materials, nutritional products, and that netiehr BAA nor any of its affiliates or subsidiaries, officers, agents and employees, nor any school district shall be or become liable or responsible for any additional expenses or liability sustained or incurred by recipient of goods and/or services as a result of any of the foregoing causes. Additionally, I acknowledge that the welfare and safety of any and all of my minor children who might be the beneficiaries of goods and/or services provided by BAA will be my sole responsibility and add my consent on their behalf that all stipulations and contingencies as stated above are applicable to them as well.
Electronic Signature of Parent/Legal Guardian*
Date*

Full Name	Date of Birth	Relationship to Child

Personal Equipment Request Application

Household Resources

Household Expenses

All information provided on this form is true and correct to the best of my knowledge.

Authorization for Release of Information

OPTIONAL: Media Release

Client's Rights

Client Grievances Resolution

Hold Harmless Agreement