Jean Wolff-Rossi Fund for Participant Involvement (Rossi Fund) Application Form

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Important Notice: The limit on each application is one (1) individual. The individual listed on this application, if awarded Rossi Funds, is the individual who needs to make all payments related to the event/conference for the categories selected on this application. This is because NCCDD's Rossi Funds are REIMBURSEMENT ONLY and NCCDD will require invoices and receipts for all expenses. If awarded Rossi Funds, additional instructions will be included in the award notice.

An application must be received by NCCDD 15 days prior to the first day of an in-state event and 30 days prior to first date of an out-of-state event. Applications are funded on a first-come, first-served basis. The NCCDD reviews applications frequently, and the decisions on all applications will be e-mailed in writing to all applicants.

The awards are limited to $1,000 per year, per person, per household for in-state events, and up to $1,200 per year, per person, per household for out-of-state events. Regardless of how many people apply, the maximum amount available for any single activity or event cannot exceed $3,000 in-state and $3,600 out-of-state. An individual may only receive one Rossi Fund award in a 12-month period.

To allow people with I/DD and family members of people with I/DD to attend events, NCCDD may decide to only partially fund the cost of attending an event. Individuals are encouraged to secure additional funding from other sources, such as other state agencies, private foundations, consumer or advocacy organizations, or their employer.

If the total amount of applications received at the same time exceeds the above limits, NCCDD will use the following criteria to fairly award the funds:

Is this a first time user of the fund?
Is this a first time attendee for this activity or event?
Will the attendee enhance ethnic or cultural diversity?
Is the applicant from rural or other underserved or unserved areas?
Which applications were received first?

**If you need assistance completing this application, please contact 1-800-357-6916. If you do not hear back from NCCDD within 5 business days of submitting an application, please contact 1-800-357-6916.

Email *

First Name *

Last Name *

Which of the following best describes you? (select one or more)

NOTE: Rossi Funds are intended to provide funding to persons with an intellectual and/or other developmental disabilities (I/DD) and/or family members of persons with I/DD to attend conferences/events.

Person with an intellectual and/or other developmental disability (I/DD)

Family member of a person with an intellectual and/or other developmental disability (I/DD)

Direct Care Worker (DCW) – for example, Direct Support Professional, Aide, Personal Assistant

Professional who advocates for persons with intellectual and/or other developmental disabilities (I/DD

Prefer not to answer

Other:

Street Address Line 1 *

Street Address Line 2 - Unit #, Apt. #, Floor Info

City

Zip Code

Phone Number

Today's Date (Date of Application)

YYYY

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