Specially Gifted Foundation Recipient Application

The first step in our gifting process at Specially Gifted Foundation is obtaining a completed potential recipient application form. This form can be found below and can be completed by a potential recipient family or someone wishing to nominate a family to potentially receive a gift. Our Gifting Team will review all applications and follow up accordingly. The completion of this form is not confirmation of eligibility to receive a gift.

REQUIREMENTS

Family currently resides in GA

Child is 1-18 years of age

Child has a medically diagnosed disability

Section 1: Who are you applying for?

Are you a recipient family or referring a family? *

Section 2: Referrer Information

Referrer Name

Referrer Phone Number

Relationship to the Family

Referrer Email

Section 3: Parent Guardian Information

Relationship to Child *

Parent/Guardian Name *

Address *

City *

State *

Postal code *

Phone *

Email *

Additional Parent/Guardian Information?

Additional Parent/Guardian Name

Additional Parent/Guardian Address

Additional Parent/Guardian Phone Number

Additional Parent/Guardian Email

Section 4: Child’s Information

Child’s Name *

Number of Siblings *

Child’s Date of Birth *

Does the child have a medically diagnosed disability? *

If yes, what is the diagnosis? *

Section 5: General Practitioner Information

General Practitioner's Name *

General Practitioner's Phone Number *

General Practitioner's Email

General Practitioner's Hospital/Treatment Facility *

Section 6: We want to get to know you!

How did you hear about Specially Gifted Foundation? *

Tell us about your child, the struggles you’ve faced, and the victories you’ve celebrated! *

Tell us how we can support you! Please list any gift ideas that would benefit your child and/or your family. *

I consent to receive text messages from Specially Gifted Foundation in regards to this application submission and any further necessary communication from Specially Gifted Foundation relevant to application status. You can reply STOP to unsubscribe at any time.