Application for Special Needs Students/Individuals Funds

Special Needs Foundation of Des Moines County

829 Harrison Ave. Burlington IA 52655 Phone/Fax 319-752-8222
Special Needs Activities Request Form

Special Needs Students/Individuals

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 individuals and may become their personal property.
5. Funds are avaliable after educational and insurance resources, state/government agencies have been reached and are discontinued upon High School graduation.
Application for Special Needs Students/Individuals 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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Special Needs Foundation of Des Moines County