Landon’s Puzzle Pieces Homeschool Grant Application

About the Grant

The Landon’s Puzzle Pieces Homeschool Grant was created to help children and young adults with Autism Spectrum Disorder (ASD) access educational, therapeutic, and developmental services that support their growth and success.

Funding may be used for approved services such as:

ABA Therapy
Speech Therapy
Occupational Therapy (OT)
Physical Therapy (PT)
ASD Evaluations or Re-evaluations
ASD Testing

Grants are awarded based on available funding and eligibility requirements.

Applicant Eligibility Requirements

To apply, applicants must:

Be between the ages of 5–21 years old
Reside in the state of Alabama
Have a documented ASD diagnosis
Submit all required documentation
Understand that recipients may not receive the grant in consecutive years

Applicant Name (ages 5-21)

First

Last

this Information how

Date of Birth

Date

Time

Age

Parent/Guardian Name

First

Last

Phone

Email Address

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Educational Information

Current School or Educational Program

Private Homeschool
Cover School
Hired Tutor
Other

Name of Private Homeschool/Tutor/Cover School

Proof of Homeschooling - One of the following must be provided:

Current Cover School enrollment verification letter
Notarized letter of intent
Signed and notarized affidavit for proof of homeschooling

Download affidavit HERE

Upload Proof of Homeschooling:

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Diagnosis Information

Has the applicant been diagnosed with Autism Spectrum Disorder (ASD)?

Name of Diagnosing Professional or Facility

Date of Diagnosis

Please upload one of the following:

Diagnostic evaluation
Letter from licensed professional
School documentation confirming ASD diagnosis

Upload Proof of Diagnosis:

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Requested Funding Information

Type of Service Requested - all provided by licensed and credentialed professionals:

Check all that apply

Name of Provider/Organization

Amount Requested

Please describe how the funding will be used:

Upload invoice or receipt for requested services:

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Applicant Story / Journey

Please write a brief paragraph sharing the applicant’s journey, needs, and how this grant would help your family.

Agreement & Signature

Media Permission

I give permission for Landon’s Puzzle Pieces Grant to use my child’s first name, story, and/or photo for promotional or social media purposes.

I certify that the information provided in this application is true and accurate to the best of my knowledge.

Clear Signature

Parent/Guardian Signature

Printed Name:

Date of Submission:

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