Summer Therapy Camp Financial Assistance

Summer Therapy Camp Financial Assistance Application

This application is for families of children with developmental delays or disabilities who are seeking financial assistance for one week of therapy camp at United Services for Children or Leaps & Bounds. This is a pilot program with a small number of approved camps. This is not an application for Variety Adventure Camp.

The summer therapy camp financial assistance program has an income guideline of $125,000 or less Adjusted Gross Income. The guideline is higher if a family has more than one child with a developmental disability diagnosis. In order to determine eligibility, please upload the first page of your 2024 Federal Income Tax Return which contains Adjusted Gross Income and a list of dependents during the application below.

If you have received Variety’s financial assistance for equipment or therapy within the past year, please contact dana@varietystl.org for separate instructions instead of completing this application.

Child’s Information

Child's Name(Required)

First Last

Birth Date(Required)

Gender(Required)

Social Security No.(Required)

Child’s Primary Diagnosis(Required)

Additional Diagnoses

Parent/Guardian’s Information

Primary Guardian(s)(Required)

Relationship to child(Required)

Primary Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

County(Required)

Phone(Required)

Email(Required)

*Your response to the following question is optional and will not affect the status of your application. The information requested is useful to St. Louis Variety in grant applications and other activities seeking additional funding for our assistance programs.

What is your child’s race/ethnicity

Request

Where will your child be attending therapy camp?(Required)

What are the dates of the camp your child will attend?(Required)

What is the cost of the program?(Required)

Household Income Information

Number of earners in the household(Required)

Number of members in the household(Required)

Earner #1’s income per Year(Required)

Current Employer(Required)

Job Title(Required)

Earner #2’s income per Year(Required)

Current Employer(Required)

Job Title(Required)

Please upload the first page of the most recent federal income tax return (Form 1040). This page should include Adjusted Gross Income and a list of dependents. If your household does NOT file taxes, but does receive SSI, please upload the most recent copy of the SSI Award letter.

You may choose to provide these documents later, but they are required to determine eligibility.

Most Recent Federal Income Tax Return

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

How did you hear about Variety?

Assessments

The funding of this program would not be possible without many individuals, companies, and foundations within the Greater St. Louis community who contribute to Variety. Our programs depend on these benefactors.
With that in mind, you will be required to complete a survey to report how your child’s piece of equipment/therapy has impacted his/her life, and that of your family.
Your responses will be critical to increasing funding for Variety programs.

Consent(Required)

I acknowledge that I will be required to complete a survey if I am provided equipment / therapy.(Required)