Assistive Technology Application | The Arc of Illinois

Basic Information

Today's Date*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

What County do you reside in?*

Phone*

Email*

Answer the following questions:

Select the option that applies most*

I am a person with a developmental disability.
My family member is a person with a developmental disability
I am the guardian/foster parent of a person with a developmental disability.

Family Member's Name*

First Last

My family member is my*

Son
Daughter
Other

Please describe other.*

What is the age of the person who will be using the equipment?*

What is the developmental disability?*

The primary purpose for an AT device is related to*

Early Intervention
Education
Community Living
Employment

Do you receive SSI?*

Yes
No

Are you Medicaid eligible?*

Yes
No

Please indicate what service (if any) you are receiving or have received from the Illinois Department of Human Services Division of Developmental Disabilities or the Division of Rehabilitation Services or the Illinois school system.*

Describe the assistive technology device for which you would like financial assistance, what your primary use of the device will be and the amount of assistance needed.*

Attachment*

Attach a copy of an evaluation/assessment showing the need for the assistive technology device along with the type of device needed.

Drop files here or

Max. file size: 50 MB, Max. files: 3.

The following statements must be signed to validate this request.

Agreement*

I am requesting assistance from The Arc of Illinois to receive Assistive Technology Equipment that has been recommended for me by a professional evaluation. I would be unable to purchase this equipment without this support. I promise to complete an evaluation form to let The Arc of Illinois know how this AT device has helped me improve my quality of life and/or live a more independent life. Without evaluations to show the positive outcomes, the funding for this program will come to an end.

I Agree

Authorized Electronic Signature

Release of Liability*

I agree to indemnify and hold harmless The Arc of Illinois and The Arc of Illinois Assistive Technology Program and any and all employees, agent or representatives of same, from damages to property or injuries (including death) to myself, and/or any other person, and any other losses, damages, expenses, claims, demands, suits, and actions by any party against The Arc of Illinois and any and all employees, agents or representatives of same, in connection with receiving assistive technology equipment from The Arc of Illinois Assistive Technology Program. I also understand it is my responsibility to get any technical assistance, data plans or any other help needed to use the equipment. Funding or partial funding for the equipment only is provided through The Arc of Illinois Assistive Technology Program

I Agree

Authorized Electronic Signature

Authorization for use of Photographs/Names*

I/We authorize The Arc of Illinois to share photographs (for promoting the program) and evaluation information to the funders of this program for the specific intent of securing continued funding. In order to continue this program, we need to know that it is successfully helping individuals live a more quality life and/or more independent life.

I Agree

Authorized Electronic Signature

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