My Voice Application

Thank you for your interest in Variety’s My Voice® program! Eligible children will receive:

An iPad
A protective case
Two years of AppleCare coverage
One communication app recommended by the child’s speech-language pathologist

Please note that this iPad is intended to be a dedicated communication device. To ensure it serves its purpose, all other apps will be removed, and internet access will be restricted. The device will only support the communication app and cannot be used for other functions.

To apply, please complete the application below. Along with the application, we require a Letter of Medical Necessity from your child’s speech-language pathologist or AAC Facilitator. Once the iPad is programmed with the selected communication app, it will be delivered to your child’s speech therapist for final customization before being handed off to your family.

Please be aware that proof of diagnosis may be required as part of the application process. After we’ve reviewed your completed application, you’ll receive an email letting you know if your child is eligible and outlining the next steps.

If you have any questions or need help along the way, feel free to reach out to:
Dana Alberto 📧 dana@varietystl.org 📞 314.720.7710

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

After receiving your application, Variety may request proof of diagnosis.

Parent/Guardian’s Information

Primary Guardian(s)(Required)

Relationship to child(Required)

Parent/Guardian's Birthdate(Required)

Primary Address(Required)

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

County(Required)

Phone(Required)

Email(Required)

Creation of an Apple ID account(Required)

I acknowledge that my birth date and phone number will be used to set up an Apple ID for my child.

*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

DMH Waiver

Variety is required to provide its funding partners with the status of program participants who receive funding through the Department of Mental Health waivers.

Does the child have a Missouri Department of Mental Health (DMH Regional Office) file?(Required)

Yes

What is their DMH ID number?

Please select if the Variety participant has any of these DMH Medicaid Waivers.(Required)

Community Support Waiver

Partnership for Hope Waiver

MOCDD (Sarah Lopez) Waiver

Comprehensive Waiver

No, the participant does not receive any of the above funding

Is the participant enrolled in Medicaid?(Required)

Yes

Speech Language Pathologist (SLP)

Speech Language Pathologist's Name?

School or Facility where the SLP works?

SLP's Email?

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)

Describe any extraordinary expenses or special circumstances. Be specific as to the expense and anticipated duration of the circumstances.

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.

Education

School Child Attends

School District Child Attends

Hidden

Names & Ages of Additional Children Residing in the Household

Assessments

The funding of equipment/therapy 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)