Heart of Variety Fund Applicant Information Packet
The Heart of Variety Fund is intended as a last resort for financial assistance for families of special needs
children in need of medical equipment/devices, physical therapy, educational resources and more. The
Fund focuses its resources on the following areas:
Variety Freedom– equipment, products and other services designed to improve a child with limited
mobility’s access to his/her community
Variety Caring – assists children with their medical needs other than mobility related resources
Variety Future Kids – assists children with educational resource to improve academic performance and
communication skills
Thank you for your interest in the Heart of Variety Fund. We look forward to the possibility of working
with your family. If you have any questions about this program, the application process or any other
Variety program, please contact us.
Sincerely,
Randall L. Hester
President and CEO
Amanda Ernst
Program Director
Variety, The Children’s Charity of Texas is a federally recognized 501(c)(3) organization (EIN 75-0630233)
5555 North Lamar Blvd, Suite K113
Austin, TX 78751
(512) 328-KIDS (5437)
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Required Information
Application Instructions & Checklist
 Complete ALL sections and forms of the application.
 Variety ONLY accepts applications through postal mail.
 Questions? Contact 512.328.5437 or email [email protected]
 Heart of Variety Fund Application
 First two pages of signed tax returns from previous two years. If you are unable to
send these documents, please contact the Variety office directly to discuss alternative
options.
 Documentation of all subsidized income. (SNAP, SSI/SSDI, Child Support, etc)

One recent paystub from employed parent/guardian.
 Two letters of recommendation from medical professionals not associated with product/ service
being requested, verifying medical diagnosis and purpose for requested item (Recommendation
form included, or separate letter on letter head also accepted), SIGNATURES REQURED. Form
included in application but can also be found online at: http://www.varietytexas.org/apply/
 Denial letter from insurance provider(s), or general insurance coverage information regarding
request (Insurance info not needed for adaptive bikes or iPad)
 HOV Vendor Registration Form (vendor providing product or service.) Form included in
application but can also be found online at: http://www.varietytexas.org/apply/
 Modified Vehicle Form, ONLY NECESSARY FOR MODIFIED VEHICLE REQUESTS. Can be found
online at http://www.varietytexas.org/apply/
 Photo of child (optional)
 Please send application, completed in full, to the address listed below.
Please do not fax or email application.
Please return the entire application and all supplemental information by MAIL to:
Variety, The Children’s Charity of Texas, Attn: Heart of Variety Fund
5555 North Lamar Blvd, Suite K113 – Austin, TX 7875
ALL INCOMPLETE APPLICATIONS EXPIRE 60 DAYS
AFTER SUBMISSION TO VARIETY AND WILL BE
SHREDDED.
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Person(s) who is completing application’s contact information:
Name
Date
Home Address
City, State, Zip
Phone (Home)
Home (Cell)
Email
Relationship to Applicant
Parent/Legal Guardian(s) Assurance
I/We stipulate that the information included in this Application is true to the best of my/our knowledge
and abilities. Further, I/we understand that the presence of inaccurate information in this Application
could result in re-evaluation or rejection of this application by Variety.
I/We understand only fully complete applications will be considered and that it is my/our responsibility to
ensure the application is complete in full before it is submitted to Variety. Furthermore, I/we understand
incomplete applications expire 60 days after submission to Variety and that all expired applications,
including supplementary documents, will be discarded and any personal information shredded.
Parent/Legal Guardian’s Printed Name
Parent/Legal Guardian’s Signature
Date (m/d/yy)
Parent/Legal Guardian’s Printed Name
Parent/Legal Guardian’s Signature
Date (m/d/yy)
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Child Recipient Information
Name
Date of Birth (m/d/yy)
Current Age
Address of Residence (including City, State and Zip Code)
Number of Siblings Living at Home and Age(s)
Telephone
Parent/Legal Guardian Information
Name
Relationship to Child
Address
City, State and Zip
Phone
Email
Name
Relationship to Child
Address
City, State and Zip
Phone
Email
Medical Information
Describe the nature of disability or need for assistance (i.e. child’s medical condition)
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Request Information Detail
Funding Request
Request and Dollar Amount Needed (Please list multiple items separately):
If Variety is unable to fulfill the entire request, is partial funding an option?
 Yes
 No
Describe the funding request(s) in detail. If requesting more than one item, please list separately.
Have you included the HOV Vendor Registration Form with your application? If not, you can download
the form at www.varietytexas.org/apply/ and send to the vendor providing the product or service
requested.
If funding request is granted, please describe how it will impact the child’s and/or family’s life.
Please add additional pages if needed.
Insurance and Alternative Sources of Funding
Insurance Information
Does the Applicant/Recipient have health insurance?
Insurance Company Name
Yes
No
Member ID#/Group#
Name of Insured
Is insurance claim (check one)
Provide phone number for claim
authorization:
Do you have a deductible?
 Partially covered by Insurance
 Not Covered
 Unsure of Coverage
In Network: $
Out of Network: $
For Therapy/Medical procedure applicants, or if applicable:
Co Pay for Services: $
Number of visits per year:
Insurance response to claim filed for the service/product, or overall coverage explanation:
Other Funding
Has applicant requested or received support from other sources, ie: legal action, charitable
organizations, scholarships, etc? If yes, please provide the following information.
Agency
Total
Nature of
Request
Amount
Received
Approval
Pending?
If denied, please state reason
$
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Annual Household Income (Adjusted Gross Income) and Uncovered Medical Expenses
Year
Household Income
Net Income
Copy of first two pages of 1040
(Line 21 on 1040)
(Take home pay; net
included in application?
income on pay stub)
20__
Yes
No
20__
Yes
No
If current year income is expected to be different from the above, please explain.
Is this a two income household? If not, please explain.
Mother/ Legal Guardian
Occupation and Employer:
Father/ Legal Guardian
Occupation and Employer:
Monthly Household Income Supplements (Please Include info for the following, if applicable)
Social Security: Retirement or SSI/SSDI (Please list per person)
TANF
Amount $
,$
Amount $
Housing
Yes
No
WIC
Yes
No
SNAP Food Benefits (formerly Food Stamps)
Amount $
Unemployment
Amount $
Start Date:
Child Support
Amount $
Family/Friend Financial Support $
Total Monthly Income Supplements
End Date:
$
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Income and Expenses Part 2
Monthly Income Source
Father/Guardian’s Take Home Pay
(Net income on paystub)
Mother/Guardian’s Take Home Pay
(Net income on paystub)
Income Supplements
(Total from Page 7)
Other Gifts, Grants, etc.
(Total from Page 6)
$
$
$
$
Other Income
$
Total Monthly Income
$
Monthly Payment
Monthly Expense
Rent or Mortgage Payment
Home Utilities
(Gas, Garbage, Electricity, Water)
Home Phone, Internet Service, and/or Cable
Cell Phone(s)
Food/Groceries
Car Payment
(List cars separately)
$
□ Own
□ Rent
$
$
$
$
Car Gasoline
$
Car Insurance
$
Child Care
$
Therapy Services
$
Health Insurance Premiums
$
(Do NOT include if this comes out of your
paycheck)
Hygiene/Personal Expenses
$
Clothing
$
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School Supplies
$
Household Repairs
$
Home Security System
$
Charitable Donations
$
Other
$
Other
$
Medical Bills
Monthly Payment $
Balance Owed $
School Loans
Monthly Payment $
Balance Owed $
Other Loans
Monthly Payment $
Balance Owed $
Total Monthly Expenses
$
Total Monthly Income
(Total from Page 8)
$
EXCESS/ DEFICIT AMOUNT
$
If expenses are greater than monthly income, please explain in detail how the difference is managed.
Has the applicant received funding from Variety in the past?
 Yes
 No
If yes, please explain and included date of past funding.
Please state how you first became aware of the Rein Rabakukk Heart of Variety Fund.
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RELEASE AND DISCLAIMER
The undersigned, by signing this form, agrees to and understands that this form includes a good faith
waiving of certain valuable rights in exchange for the providing of certain equipment and/or other
devices and any and all other support or help received by the undersigned from, Variety, The Children’s
Charity of Texas, and all of their related entities, members, employees, officers and directors, attorneys,
agents, successors and assigns (all collectively referred to as “Variety”). By signing this form the
undersigned acknowledges that they are releasing Variety and other parties of liability for themselves,
any of their natural minor children, or minor children in their legal guardianship. The use of any
equipment provided by Variety, even in the event of a malfunction resulting in injury, may give rise to
liability on the part of Variety and I/we hereby fully release any action I/we may have with regard to
same. I/we recognize on behalf of myself/ourselves and any minor under my control that the use of or
participation with any equipment provided involves subjecting oneself to risk of injury, and I/we hereby
agree to obey any and all safety standards and the instructions of the Variety staff, as well as hold all
entities or individuals involved with Variety free from liability.
Variety is in no way endorsing or recommending a particular course of treatment and that all treatment
decisions should be made by the child’s physician and parents/guardians.
Variety is in no way responsible for reclaiming, disposing of, maintaining or repairing any equipment
provided. It is my/our sole responsibility as the recipient or recipient’s legal guardian(s) to maintain,
repair and/or dispose of the equipment. Any costs that may be associated with the equipment, such as
installation, delivery, labor, disposal, etc., that are not explicitly stated in writing from Variety as Variety’s
responsibility, is my responsibility. Additionally, I/we, and not Variety, agree to be responsible for
insurance with any and all costs connected therewith.
By my signature below, I certify that the information provided in this application is accurate and
complete and I have answered all questions to the best of my knowledge and ability. I further authorize
Variety and any of its authorized representatives to investigate any and all information contained in this
application in order to verify the accuracy of same.
I further realize that providing false information or misrepresenting the facts in this application is a
serious matter and will be grounds for Variety to terminate any assistance agreement without notice
and/or seek repayment of any and all amounts previously paid to any third parties or to me or my family
by Variety pursuant to this application. I also agree to hold harmless and indemnify Variety, The
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Children’s Charity of Texas, and its board members, officers, employees and volunteers from any liability
which may arise from investigation into the accuracy of the information presented in this application as
well as any actions that are taken if information provided is not accurate.
MEDICAL RELEASE:
(initial)
_(initial)
I/we understand that the involvement with Variety is voluntary. I/we assume the risk of any and all
injuries, which may occur as a result of participating with Variety.
AUTHORIZATION FOR EMERGENCY TREATMENT:
(initial)
(initial)
I/we hereby give permission for myself or if applicable, any minor children under my control to receive
emergency medical treatment, including hospitalization, in the event I/we for what ever reason, am not
present and cannot be reached when such treatment is needed.
PHOTO/MEDIA RELEASE:
(initial)
(initial)
I, my minor child, or a minor child under my legal guardianship (individually and collectively referred to
as Participants), intend to participate in one or more programs of Variety, The Children’s Charity of
Texas (Variety). In consideration of this participation, Participants grant to Variety all right, title, and
interest in any and all photographs, images, video, or audio recordings of Participants or Participants’
likeness or voice made by Variety in connection with the Program. Participants further authorize Variety
to use Participants’ name and personal, biographical, and medical information in connection with any
electronic or print publications, social media posts, fundraising events, or other promotional activities
by or on behalf of Variety and its programs. Participants release Variety, its employees, and agents from
any and all claims of damages for libel, slander, invasion of the rights of privacy, or any other claim
based on, arising from, or connected with the use of such information or material. Participants
understand and agree that they will not receive compensation for any use of such information or
material.
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DISCLAIMER:
(initial)
_(initial)
In the event that equipment, devices, assistance with therapeutic programs and any other type of item
furnished to me, including all types of supports provided through this and any affiliate of Variety it is
expressly understood that the item provided or assisted has no warranty whatsoever from Variety, their
officers, directors, employees, members, or other individuals associated with Variety (hereinafter
collectively referred as “Variety”). It is expressly understood that Variety is merely a funding source and
as such delivers no warranty and any malfunction or injury resulting from the use of anything provided
by Variety carries no liability on the party of Variety. Additionally, Variety is not responsible for
reclaiming, disposing of, maintaining or repairing any of the items provided. It is the sole responsibility
of the undersigned to maintain, repair, and/or dispose of the items provided.
Any cost that may be associated with the item provided, including installation, delivery, labor, disposal,
repair, replacement etc., that are not explicitly stated on the application and/or award letter from
Variety is the sole responsibility of the recipient’s legal guardian(s). The recipient is responsible for
ensuring compliance with all codes and hereby releases Variety from such responsibility. Additionally,
recipient is responsible for maintaining compliance with all applicable building codes, and/or federal,
state, or local regulations.
RELEASE TO CONTACT:
(initial)
(initial)
I, my minor child, or a minor child under my legal guardianship (individually and collectively referred to
as Participants), intend to participate in one or more programs of Variety, The Children’s Charity of
Texas (Variety). In consideration of this participation, participants authorize Variety to contact anyone
associated with the care, medical or otherwise, of the child or any person(s) mentioned in the child’s
Rein Rabakukk Heart of Variety Application and further authorize Variety to discuss any personal
information given in their application with said person(s). Participants release Variety, its employees,
and agents from any and all claims of damages for libel, slander, invasion of the rights of privacy, or any
other claim based on, arising from, or connected with the use of such information or material.
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RELEASE OF ALL CLAIMS (Liability Release):
(initial)
_(initial)
I/we have read this form and are aware of and understand that in consideration of and in exchange for
the right of myself or any minor child under my control to participate with Variety and I/we agree to
indemnify and hold harmless, release and forever discharge, Variety and all their employees, officers
and directors, attorneys, agents, successors and assigns from any and all actions, suits, claims, demands,
judgments, damages and liability in law and in equity which may arise as a result of my/our participation
with Variety, including costs, and reasonable attorney’s fees. This release shall serve as a release not
only of myself and any minors under my control but also to all heirs, executors, administrators, personal
representatives, parents, guardians, and for all members of their family. As a parent or guardian
signing for a minor it is agreed that I/we agree to these terms for the minor, for us individually, and as
a parent or guardian. Any and all individuals signing this form acknowledge that Variety and its
affiliates have relied upon the good faith execution and delivery of this form. The parties hereto signing
this form assume the risk of any and all injuries, which may occur while participating with Variety.
I/we have read and understand this form, have had an opportunity to ask question, have had the
opportunity to consult an attorney of my/our own choosing, and freely agree to the terms as expressed
in return for participation with Variety in their programs. No oral agreements, either prior to or after
signing this agreement shall control over this written agreement.
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Signed this the
day of
, 20 _.
Printed Name of Parent or Legal Guardian
Signature of Parent or Legal Guardian
Printed Name of Parent or Legal Guardian
Signature of Parent or Legal Guardian
BEFORE ME, the undersigned Notary Public in and for the State of Texas, personally appeared
who acknowledged the execution of the above, on this
, 20 _.
day of
Notary Public in and for the State of Texas
BEFORE ME, the undersigned Notary Public in and for the State of Texas, personally appeared
who acknowledged the execution of the above, on this
, 20 _.
day of
Notary Public in and for the State of Texas
State of Texas
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Variety, The Children's Charity of Texas
Recommendation Form
MUST BE FILLED OUT BY MEDICAL PROFESSIONAL NOT ASSOCIATED WITH PRODUCT/SERVICE BEING REQUESTED
Applicant Name
Date of Completion
Recommender Contact Information:
Name
Phone Number/ Email
Relationship with Applicant
Company and Position
License Number (If Applicable)
Please state the applicant’s diagnosed condition:
What product or service are you recommending?
Why is the request medically necessary?
How will the request affect the child’s life?
Signature of Recommender
Variety, The Children's Charity of Texas
Recommendation Form
MUST BE FILLED OUT BY MEDICAL PROFESSIONAL NOT ASSOCIATED WITH PRODUCT/SERVICE BEING REQUESTED
Applicant Name
Date of Completion
Recommender Contact Information:
Name
Phone Number/ Email
Relationship with Applicant
Company and Position
License Number (If Applicable)
Please state the applicant’s diagnosed condition:
What product or service are you recommending?
Why is the request medically necessary?
How will the request affect the child’s life?
Signature of Recommender
Heart of Variety Vendor Registration
MUST BE FILLED OUT IN FULL BY VENDOR
Vendor Name
Contact Name
Type of Business
Certificate # (if applicable)
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
Email Address
Client (Child's) Name
Cost of product/service
Description of product/service being requested:
Only applicable for Applied Behavior Analysis Treatment
Requests
Please check all that apply regarding the ABA services:
Therapy program is designed by BCBA-D or BCBA
Therapy is provided by BCBA-D or BCBA
Therapy is supervised by BCBA-D or BCBA
Will insurance cover the
product/service?
Insurance Provider
Yes
No
Partial
Do Not Know
Insurance response to claim filed by vendor, or overall coverage explanation.
Vendor has submitted their W9 to Variety:
Yes
No, but will submit to [email protected]
Consider a Gift
You are receiving this form today because you are a vendor who is providing a product
and/or service that a child needs. Variety, The Children's Charity is a 501(c)3
organization that provides funding to help purchase these products and/or services to
children who have special needs.
Please consider offering a discount to Variety so that we may continue
serving many more children in Texas with special needs.
I would like to provide a discount!
Yes!
No
If providing discount, please include
$ amount, or percentage: