CSDSA 2017 Scholarship Form-PLEASE DON'T PRINT OUT THIS FORM-THIS IS FOR ONLINE SUBMISSION ONLY!
Complete the following information. Please scan and email any receipts to scholarship@csdsa.org or mail them to:
CSDSA
PO Box 2364
Colorado Springs, CO 80901
Remember to include enough postage!
Date of Application
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Applicant's Name
Your answer
Applicant's Age
Your answer
Name of Parent/Legal Guardian
Your answer
Address, City, State and Zip Code
Your answer
Phone Number
Your answer
Email Address
Your answer
Is your CSDSA membership current?
Category of funding requested (select one)
Specific items or services requested
Your answer
Estimated cost/amount of items/services requested
(REMINDER: THE CSDSA DOES NOT PAY APPLICANTS DIRECTLY. IF THE SCHOLARSHIP APPLICATION IS APPROVED, THE CSDSA WILL EITHER REIMBURSE** THE APPLICANT OR FORWARD APPROVED FUNDS TO THE PROVIDER.) **Please email receipt to scholarship@csdsa.org if this is a reimbursement request.
Your answer
Briefly explain how your request will benefit your family member with Down syndrome.
Your answer
Date by which funds are needed
MM
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DD
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YYYY
Have you explored other resources for securing funds?
Have you applied for CSDSA scholarship funding since January 1st of this year?
What is the anticipated out-of-pocket expense for this request?
Your answer
Is there insurance available to applicant
THIS SECTION IS FOR MEDICAL SERVICES ONLY. PLEASE SKIP THIS HIGHLIGHTED SECTION IF YOUR REQUEST IS FOR AN EDUCATION, RECREATION, OR TRUST ASSISTANCE SCHOLARSHIP.
Upon approval, please make the payment to:
Please include: NAME, ADDRESS, CITY, STATE, ZIP CODE
Your answer
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