Request Resources March 6, 2018 by Telic Empowerment Telic provides educational, financial, independent living, and health resources to benefit families that have a special needs child or young adult. If you are in need of assistance please fill out the form below. Privacy Policy Terms of Service Resource Request Form RM_StatsName *Requestor's nameEmail *Phone Number *In which county do you currently reside? *Select an optionDekalbRockdaleNewtonGwinnettFultonHenryCobbOtherAge of Disabled Child/Adult *Select an option3-5 years old6-10 years old11-17 years old18-22 years old23 years old +please select oneType of Disability *Type of Resource Requested * Medical Financial Educational Independent Living Description of what you are looking for. Be specific *example: school not adhering to IEP, childcare for child with autism and aggressive behaviorWhat is your annual family income?Select an option$0-$35000/yr$36000-$49000/yr$50000-$75000/yr$76000-$99000/yrAbove One Hundred Thousand/yr*Needed to qualify for certain grantsPerson Requesting Resources is *Select an optionParent/GuardianCaregiverMember of a Nonprofit organization/church/schoolEmployee of a social services or related agency or organizationI have read and agree to Telic's Terms and Agreements * Privacy Policy www.telicempowerment.org/privacy-policy Terms of Service www.telicempowerment.org/terms-of-service Both checkboxes required Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu. Like this:Like Loading...