Shannan Jursa, Agent and State Farm have partnered to donate 200 Amazon Echo Show 5 smart display systems to the Autism Society of Mahoning Valley. If your tween, teen or adult with an autism diagnosis would benefit from one of these devices, please fill out this grant application and submit by: September 12, 2021. You must be the parent or the guardian. These are to be used by the individual with autism to help them with their independence needs and/or socialization. We are prioritizing individuals aged 12 years of age through adulthood. If we have extras once this age group has had a chance to receive we will then open up to all ages. Individuals must live in the counties we serve, which are Mahoning, Trumbull and Columbiana counties.

ASCO Echo Show Grant Application


* All Fields Required

Name of Grant Applicant:

Male     Female
Birthdate:

Current Age:

Address: (Please spell correctly and add in apartment number if applicable)

City:

State:

Zip:

County of Residence:

Diagnosis:

Telephone:

Name of Person Completing Request Form:

Relationship to Recipient:

Telephone:

Email:


How will an Amazon Echo Show 5 benefit the applicant? What disability-related issues will the device address (how will it make life easier, safer, or more independent)? Please be brief, but detailed:


What programs do you currently attend that Autism Society of Mahoning Valley offers?


What programs would you like the Autism Society of Mahoning Valley to offer?


By submitting this application, I affirm that the facts set forth in it are true and complete. Additional information or documentation may be requested by the Grant Committee. All information will be kept confidential.
Date:

I agree:

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference or age. All information will be kept confidential.
Thank you for completing this online application.
Autism Society of Mahoning Valley - PO Box 151, Canfield, OH 44406
Please contact us by email with any questions at: info@autismmv.org
330-333-9609 --- AutismMV.org