Application for Assistance
Our mission is to educate, enhance and support families with special need children in Des Moines County. If you are seeking assistance for medical bills, complete documentation will be required.
Date
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YYYY
Parent's Name
Your answer
Child's Name
Your answer
Child's Birthdate
MM
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DD
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YYYY
Address
Your answer
Do you live in Des Moines County? Applicants must reside in Des Moines County, Iowa
Phone Number
Your answer
Disablity
Your answer
What assistance are you seeking from Through Joshua’s Eyes?
Your answer
Have you applied for assistance elsewhere? If so, where?
Your answer
List any other information you feel would be helpful to us in determining your eligibility for assistance.
Your answer
By submitting this form, individually or as a parent or legal guardian, I hereby release Through Joshua’s Eyes and individuals on the Board of Directors from any claims, action or suits of any kind.
Would you be interested in receiving information about the Through Joshua's Eyes Support Group?
Submit
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This form was created inside of Burlington Comm School District.