CSDSA 2018 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 *
MM
/
DD
/
YYYY
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
/
DD
/
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
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms