The Starry Foundation

Grant Application Pilot Program

Starry Foundation offers families who have no health insurance or who only have benefits through Arizona state insurance (AHCCCS) access to a comprehensive multidisciplinary diagnostic evaluation for children with sensory differences and/or who may be on the autism spectrum. Starry Foundation is able to fund evaluations thanks to our generous private, corporate, and community charitable donors.

Qualifications are based on families’ annual income, lack of private insurance and age of child (6-years old and above). Please complete the application indicating why you think your child needs access to this multidisciplinary diagnostic evaluation. Applications cannot be processed without verification of at least 2 months’ current income, or proof of AHCCCS coverage. This could be copies of 2 months of paystubs or bank statements. If submitting bank statements please highlight the payroll deposits. If both parents are employed please include information for each.

Grant Application Form

Child's Name

First Name

Last Name

Child's Date of Birth

YYYY

Parents’ Name

First Name

Last Name

Parents’ Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Phone Number

(###)

###

####

Contact Email

Does your child have a history of any neurological or medical diagnosis?

If yes, please list

Was your child in AZIEP or Developmental Preschool?

If yes, how did they qualify?

Is your child in any kind of DDD program?

If yes, how did they qualify?

Has your child received any previous developmental diagnostic evaluations?

If yes, what were the results?

Is your child on a waitlist for a diagnostic evaluation?

Please check all that apply:

No private insurance

Family qualifies as Low Income (less than $33,948 per year for a family of four) Family is AHCCCS/Medicaid approved

Family qualifies for HUD housing

Symptoms/Concerns (Why does your child need an evaluation?)

Is there a family history of Developmental Delays or Autism Spectrum Disorder, or a sibling who has a diagnosis already?

What information do you hope to gain from this evaluation?

Any other information you would like to share as to why your family needs this grant?

Annual gross income information required—please itemize:

If your family does not yet have AHCCCS/Medicaid, HUD housing, etc., and you still might qualify, please fill out the following and send in proof of income/savings with your application

Total yearly household gross income:

Current savings account balance:

Number of family members in the home?

How did you hear about this grant?