Riverbend Down Syndrome - Monetary Request Form

Monetary Request Form
The purpose of the Riverbend Down Syndrome Association (RDSA) Monetary request form is to provide financial assistance to individuals and families with Down syndrome so they may participate in activities such as classes, camps, organized sports, etc.; therapies including PT, OT, and Speech. Funding can also be used to request financial assistance for immediate family members who would like to attend local, regional, or national conferences, seminars or training sessions that address issues pertaining to Down syndrome and other related topics. Please read this document in its entirety before submitting this request. For questions call Peggy Mitchell at 618-402-8248.
Parent/Guardian Name*
Date*

MonthDayYear
Date
Address*

Street Address

CityState

Postal / Zip Code
County*
Home Phone*
Cell Phone
Email*
Child's Name*
D.O.B.*
Activity for which you are seeking funds (please include copy of brochure or specific information about activity/organization)*
File Upload

Cancelof
Dates you are interested in attending*
Location of Activity*
Cost of Activity*
Amount Requested from RDSA*
Check Made Payable to (the provider of the activity or parent)*
Benefit for caregiver/child *
Have you received RDSA funds in the past?*

YesNo
If yes, when
Name of previous event/activity for which you received funds
Should be Empty: