Application for Special Needs Students/Activities

Special Needs Foundation of Des Moines County

829 Harrison Ave. Burlington IA 52655 Phone: 319-752-8222 Email: ricci@specialneedsdmc.org
Special Needs Activities Committee

This form is for Special Needs Teachers/Service Providers/Individuals

Request Form for Items or Funds for Activities

Funds are available through the Foundation to teachers/service providers/individuals in the following school/educational/service programs:
- 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/activities for students' use within the classroom or community will be considered
3. Items/services/activities are geared towards helping a student/individual become more independent, used for educational purposes or to enhance the quality of their life.
4. Items purchased 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/Teachers/Individuals/Service Providers Funds
Date

MonthDayYear
Date
Teacher, Class Name/Service Provider/Individual or Student
Item(s)/Services/Activity Needed
Where to Purchase (if specific items request)
*(If an order form is needed, complete form and attach a copy to this application.)
Upload Information here

Cancelof
Costs (Including shipping if this is a specific items request)
Name (contact responsible for this form, funds received, in charge of activity, etc.)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Delivery Address (Please fill this out for items and funds requests)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature
Should be Empty:

Special Needs Foundation of Des Moines County

Application for Special Needs Students/Teachers/Individuals/Service Providers Funds