My Voice® Program Application

BEFORE YOU BEGIN, please click here to review our eligibility guidelines and process for applying. If you prefer, you can download the voice application by clicking here. To save your progress and continue the application later, please scroll to the bottom and click “Save Progress and Continue Later” in the red box. If you need an application mailed to you, please contact us at info@varietypittsburgh.org or at (724) 933-0460 with your name and address.

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

Child's Information

How did you hear/learn about Variety's programs?*

^This info. helps us to build a stronger program and ultimately help more kids.

Last Name (Child)*

First Name (Child)*

Diagnosis (es)*

Date of Birth*

Age*

Gender*

Race/Ethnicity:*

Asian/Asian American

Black/African American

Hispanic/Latino/Latina/Latinx

Native American/American Indian/Alaskan Native/Indigenous

White/Caucasian/European

Middle Eastern/Northern African

Native Hawaiian/Pacific Islander

Other

Address*

Street Address Address Line 2 City State ZIP Code

County Name*

School Child Attends*

School District Child Resides In*

Any Union Affiliation?

^It is helpful to know if if anyone in your family is a member of a local union, as we have close partnerships with unions.

Primary Insurance Company*

Note - we do not contact insurance. This is for data purposes only.

Secondary Insurance Company

^Put n/a if you don't have secondary insurance.

Home Phone Number*

Cell Phone Number

Work Phone Number

Best Time to Call*

Email Address*

^Email is used to keep you updated on the status of the application, including its approval.

My Voice® Program

Our My Voice® Program is financed {in part} by a grant from the Commonwealth of Pennsylvania, Department of Community and Economic Development as well as generously funded by community donations.

Speech Therapy Background

Has your child received a communication device from Variety?*

Yes

Please note, Variety is limited to providing a maximum of 3 communication devices per child over their lifetime.

Has your child ever had a speech and language evaluation?*

Yes

Unsure

Does your child currently use a communication device at SCHOOL?*

Yes

Unsure

Does your child currently use a communication device in THERAPY?*

Yes

Unsure

Does your child have a communication device to use 24/7 at home, school, and throughout the community?*

Yes

Unsure

Does your child currently work with a licensed Speech Language Pathologist (SLP)?*

Yes

Unsure

SLP's Name*

SLP's Organization*

SLP's Phone Number*

SLP's Email Address

Please describe how a COMMUNICATION DEVICE will impact your child and whole family. What is your hope with this device? Anything you can share will be vital to better understand the need and be able to help even more kids.*

If re-applying, please briefly tell us how the first communication device made an impact.

MY VOICE Letter of Medical Justification (LMJ)

Drop files here or

Max. file size: 256 MB.

My Voice LMJ: The My Voice LMJ must be completed by a licensed Speech Language Pathologist (preferably with ASHA Certification) who also completed an evaluation of the child using an iPad, and can then provide a recommendation for the appropriate communication application that successfully works for the child.

Please click here for more specifics on the LMJ.

Household Members

Please list all the people who live in your household, including the child applying. Start with yourself.

How many members live in your household?*

Household Member #1

Last Name*

First Name*

Middle Initial

Relationship to Child*

Gender*

Date of Birth*

Household Member #2

Last Name*

First Name*

Middle Initial

Relationship to Child*

Gender*

Date of Birth*

Household Member #3

Last Name*

First Name*

Middle Initial

Relationship to Child*

Gender*

Date of Birth*

Household Member #4

Last Name*

First Name*

Middle Initial

Relationship to Child*

Gender*

Date of Birth*

Household Member #5

Last Name*

First Name*

Middle Initial

Relationship to Child*

Gender*

Date of Birth*

Household Member #6

Last Name*

First Name*

Middle Initial

Relationship to Child*

Gender*

Date of Birth*

Household Member #7

Last Name*

First Name*

Middle Initial

Relationship to Child*

Gender*

Date of Birth*

Household Member #8

Last Name*

First Name*

Middle Initial

Gender*

Relationship to Child*

Date of Birth*

Household Member #9

Last Name

First Name

Middle Initial

Gender

Relationship to Child

Date of Birth

Household Member #10

Last Name

First Name

Middle Initial

Gender

Relationship to Child

Date of Birth

For Children Currently Living in Foster Care:

Foster Care County

County Caseworker - Name, Email, Phone

Foster Service Agency Name

Foster Service Agency - Contact Name, Phone, Email:

Income

Please complete the information below for all persons in your household that have income.

What is the total monthly income for your household (approximately)?*
*if applying for a child in Foster Care, please do not complete - type foster care instead.

How many members in your family have income?*
*if applying for a child in Foster Care, please select 1 household member and submit Option 3, #6 (i.e. documentation from county and/or foster care service agency).

Household Member #1:

Whose income is this?

Source of income (e.g. name of employer, unemployment, social security, etc.)