CSDSA 2021 Scholarship Form
Complete the following information. Do not print out this form-it is for online submission only. Email receipts to scholarship@csdsa.org
Email address *
Date of Application *
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Applicant's Name *
Applicant's Age *
Name of Parent/Legal Guardian *
Address, City, State and Zip Code *
Phone Number *
Is your CSDSA membership current? *
Category of funding requested (select one) *
Specific items or services requested *
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.
Briefly explain how your request will benefit your family member with Down syndrome. *
Date by which funds are needed *
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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? *
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
A copy of your responses will be emailed to the address you provided.
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