Cookies For iPads Online Application

Cookies For iPads Application

Fields marked with an * are required

INDIVIDUAL WITH AUTISM

MOTHER/GUARDIAN 1

FATHER/GUARDIAN 2

If father's address is the same, you do not need to fill in the address below. If you're a single parent - Go You! It's a tough job and we admire and support you! You also do not need to fill out the information below. 

GENERAL INFORMATION

PROVIDER/SCHOOL INFORMATION

If individual does not see speech pathologist, list diagnosing doctor's first name.

If individual does not see speech pathologist, list diagnosing doctor's last name.

RESPONSIBLE EDUCATOR

Part of the requirements for qualification in the Cookies For iPads program is the oversight by an educational or medical professional of iPad usage. Ideally, the child's special education instructor would be responsible for finding appropriate programming and tools and for utilizing the device as an instructional aide and communication tool both in the classroom, and at home. As such, we do require that you list a responsible party.

TERMS

In order to qualify for the Cookies For iPads Program, I understand that I am required to participate in no less than three (3) volunteer assignments. These assignments will be provided by the managers of the Cookies For iPads program. I understand that I am not eligible to receive the iPad until my volunteer obligation has been fulfilled, unless an alternate arrangement has been made with Cookies For iPads. By typing "YES" in the box below, I acknowledge that I have read and agree to these terms and conditions. Typing anything other than "YES" will result in the disqualification of this application.

The above information is freely given to process this application request. By typing my name in the box below, I attest that all information included is true and accurate and gives Cookies for iPads permission to contact the professionals listed to verify and discuss diagnosis, behavior, and speech abilities of the individual applying for the iPad. I understand that falsifying information will immediately disqualify this application.
I understand that the iPad is to be used solely as a communication/therapeutic device for the individual listed on this application. If Cookies For iPads receives evidence that the individual is not being granted access to the iPad assigned to them, I understand my family will have to return the iPad or pay Cookies for iPads the replacement value of an iPad. I confirm that I understand and agree to abide by these rules.

I understand that failure to type my name in the box below, or typing anything other than my  name in the box below, will result in the automatic disqualification of this application.