Date
Name of person filling out application
Name of person for whom funding is requested
Age of individual for whom funding is requested
Address
City , NH. Zip
E-mail address
Phone number
Best time to contact
Is the individual currently enrolled in school? Yes No
At what level?
Where?
What supports are being provided to insure success (tutoring, direct instruction,program modifications)? None Tutoring Direct Instruction Program Modifications Other
Is the individual currently working with Vocational Rehabilitation? Yes No
If so, in what capacity?
Is the individual in a supported employment environment? Yes No
Where?
Please provide a brief description of the job / responsibilities
Please describe the purpose of requested funds

How do you hope this assistance will improve the quality of the individual's life?

Applications for assistance are considered on a monthly basis at the Board of Directors meeting. Amounts allotted are at the discretion of the Board of Directors. Availability of funding, as well as access to other supports will be factors in the determination. All decisions are final.