APPLICATION FOR STATEWIDE FAMILY SUPPORT  PROGRAM
 

(Please Print or Type)

 *Please read instructions prior to completing application.

PARENT/FAMILY MEMBERS NAME: ______________________________________________

 ADDRESS: _____________________________________________________________________

CITY:  __________________________       ZIP CODE: ___________________

HOME PHONE: __________________     WORK PHONE: _____________________

The child’s diagnosis and source of diagnosis must be listed above.  Documentation of the child’s diagnosis must accompany this application form.  Documentation of the child’s functional limitations such as Birth to 3 evaluations, psychological-educational testing scores or other evaluations pertinent to the child’s diagnosis should be submitted. If questions should arise regarding documentation, please call the toll free number listed below.

Family member’s relationship to child with special needs: ________________________________

Does your child with special needs reside in your home? ________________(yes or no)

What is your funding request?

__________________________________________________________________________________________

__________________________________________________________________________________________

What is the estimated cost? (Please submit an itemized estimate with this application)

 __________________________________________________________________________________________

__________________________________________________________________________________________

Briefly describe how this funding will assist your family in meeting your child’s special needs:

 _______________________________________________________________________________________________

________________________________________________________________________________________________

I understand for a child to be eligible for the Statewide Family Support Program he/she must have a diagnosed developmental disability, be under the age of 22, and must reside within a family member’s home.  I hereby attest that my child(ren) meets the eligibility requirements of eligibility for the Statewide Family Support Program.

SIGNATURE_____________________________________________________________DATE____________

Department of Human Services; Statewide Family Support Program

c/o 500 East Capitol  Pierre SD 57501

Phone Toll-Free 800-265-9684  or  605-773-3438

FAX 605 773-7562