top of page
DONATE
HOME
ABOUT JAX MEMORIAL FUND
EVENTS & PHOTOS
DONATE
SCHOLARSHIP APPLICATION
CONTACT
SHOP
More
Use tab to navigate through the menu items.
Search
Child's First Name
*
Child's Age
*
Diagnosis
*
Date of Diagnosis
*
Month
Day
Year
Is your child verbal or non-verbal?
*
VERBAL
NON-VERBAL
Does your child use a speech generating device?
*
YES
NO
Who recommended you to receive toys/equipment? (i.e. OT, PT, Teacher, etc.)
*
What types of sensory equipment can your child benefit from?
*
What is the estimated cost of items your child would use the scholarship money for?
*
Where does your child attend school?
*
Does your child receive any additional services?
*
NO
YES
Please list the additional services
Does your child have any behavioral difficulties?
*
NO
YES
Please list your child's behavioral difficulties
Your Name (First, Last)
*
Email
*
Phone
*
Submit
bottom of page
