REQUEST FOR ASSISTANCE WITH TRAVEL EXPENSES TO CONFERENCE/WORKSHOP
 

Applicant Name: ___________________________________________________

Applicant Address: _________________________________________________

Daytime Phone Number: _________________________________

Email (optional): ________________________________________

Check one of the following:

_____ I am a person with a developmental disability.

_____ My family member is an adult with a developmental disability.

_____ I am the parent of a child with a developmental disability.

_____ I am the parent of a child at risk of a developmental disability.

_____ I am the guardian for a person with a developmental disability.

Age of person/child with disability _____

OPTIONAL: White _____ Native American _____ Other ___________________

 Title of Project/Event: ____________________________________(Attach agenda)

Date(s) of Event: ______________   Location: ____________________________

Why do you want to attend this meeting, conference or workshop?

How will you share the information gained once you return?

Have you attended this activity before? _____ Yes _____ No

If yes, when did you last attend this event? Date:

Have you received assistance from the Council before? _____ Yes _____ No

If yes, for what event? __________________________ When? ________________

Amount received $_____________

By signing below, I verify that the information provided is accurate to the best of my knowledge and that I have reviewed the Federal Definition of Developmental Disabilities and qualify as an individual with a developmental disability or the family member/guardian of an individual with a developmental disability.

Signature: _________________________________  Date:_________________