SN Students/ Special Olympics

Special Needs Foundation of Des Moines County

829 Harrison Ave. Burlington IA 52655 Phone/Fax 319-752-8222
Special Needs Students/ Special Olympics Committee
Funds are available through the Foundation to students in the following school program:
- Severe and Profound/ Multiple Handicaps
- Mental Disability
- Students with Physcial Disabilities
- Early Childhood Special Education
Criteria
1. Resident of Des Moines County.
2. Equipment/services for students' use within the classroom will be considered
3. Items/services are geared towards helping a student become more independent, used for educational purposes or to enhance the quality of their life.
4. Items purchases are for indivualds and may become their personal property
5. Funda are avaliable after educational and insurance resources, state/government agencies have been achaused and are discontinued upon High School graduation.
Application for Special Needs Students Funds
Date:

MonthDayYear
Date
Student/Class name:
Item(s)/Services Needed:
Where to Purchase:
*(If an order form is needed, complete form and attach a copy to this application.)
Upload Information here:

Cancelof
Costs (Including shipping, etc.):
Teacher Name:
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Delivery Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature:

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This application has been approved by Special Needs Committee Member.
Committee Members

Barb Fenton, Chair

Judy Riffel

Margie Swanner

Amy Hayes

Lisa Daly-Begner
Should be Empty:

Special Needs Foundation of Des Moines County

Application for Special Needs Students Funds