Application date*

Name of Person with Down Syndrome*

DOB of person with Down Syndrome*

Does this person receive food stamps?*
YesNo

Does this person receive free or reduced lunch?*
YesNo

Did your family attend last year's Buddy Walk*
YesNo

Did your family participate in any DSAB fund raising events? For example FirstGiving Page, garage sales, host any fundraising parties etc.*
YesNo

Name of Parent(s) or legal guardian*

Address of Parent(s) or legal guardian*

Email of Parent(s) or legal guardian*

Phone of Parent(s) or legal guardian*

Name of entity that will receive DSAB funds*

Address of entity that will receive DSAB funds*

Phone Number of entity that will receive DSAB funds*

Brief description of services or activity. Please include date(s)*

Total amount required for service or activity (please provide documentation)*

Amount family will pay towards cost*

Amount of grant/scholarship/other offered by others for activity/service*

Dollar amount of DSAB funds requested*

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