Please be prepared to attach your household Income Tax Return to the end of this application. Please only provide the first 2 pages and black out all social security numbers. 

An Income Tax Return is required so Feeding Matters can verify your household's income. If you are unable to provide this, please contact Feeding Matters at 800.233.4658 or programs@feedingmatters.org before continuing with your application.

By accepting the Feeding Matter Family Assistance Program funds: 

• I agree to spend all money awarded to me by Feeding Matters Family Assistance Program on items, services, or medical treatments that directly relate to caring for a child with pediatric feeding disorder within one year of receiving funds. Examples of such expenses include, but are not limited to, medical or caregiving expenses such as a registered dietitian, clinical psychologist, feeding tube supplies, feeding programs, travel for treatment, special formulas, household items related to caring for a child with pediatric feeding disorder (e.g., carpeting, feeding supplies, blenders, etc.), pediatric feeding disorder education, or family counseling. 

• I understand that if Feeding Matters determines, in its sole discretion, that Family Assistance Program funds have been used to cover costs not directly related to caring for a child with pediatric feeding disorder, then Feeding Matters retains the right to seek repayment of such funds from me.
• I agree that upon receiving an award from Feeding Matters, I will make myself available for public relations and marketing outreach. 
• I agree to share our PFD story on Feeding Matters website and/or create a short video on what receiving an award has meant to my child and family. 

I grant permission to Feeding Matters and its employees to use photographs taken of: 

and me and submitted by me in connection with my application for assistance. I also grant permission for Feeding Matters to quote my words from any written material that I have submitted. These images and/or quotes may be used on the Feeding Matters and other websites, including social media sites, in promotional materials, educational materials, documentaries (e.g., video documentaries), public service announcements, grant applications, digital or print newsletters, Family Assistance Program materials, derivative works, or for similar purposes without compensation to me.

I understand and agree that such photographs of:

and me may be placed on the Internet. I also understand and agree that I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs of me. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, and any reproductions thereof are and shall remain the property of Feeding Matters. I hereby agree to release, defend, and hold harmless Feeding Matters and its employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper, via electronic media, or on Web sites, from any claim, damages, or liability arising from or related to the use of my words, photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction, or production of the finished product, its publication, or distribution. 

I affirm that the information in this application and uploaded documents is true and accurate according to my knowledge.