Zetosch Fund Application

Welcome to the UCP Oregon Zetosch Fund Application Form.

Thank you for taking the time to complete this application and share information about how funding may support a child or youth with a disability.

Reminder: this online application cannot be saved and completed later. Please make sure you have gathered the necessary information and have the documents available to upload before you begin.

Who is completing this application?

Please tell us about the person filling out this application.
Your Name - Name of Person Completing this Application

First NameLast Name
Relationship to child/youth?

Other
Your Organization (if applicable)
Your Email
Your Phone Number
Format: (000) 000-0000.
How did you first hear about the UCP Oregon Zetosch Fund?

Child/Youth Applicant Information
Child/Youth Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Disability
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Primary Contact Information

Please provide the primary contact for the child or youth applicant. If the applicant is under 18, this should be a parent or legal guardian. If the applicant is 18-21, this may be the youth, a parent or legal guardian, or another family member involved in supporting them.
Primary Contact

First NameLast Name
Relationship to child/youth?

Other Family
Email
Phone Number
Format: (000) 000-0000.
Educational, Vocational, Transition, or Other Learning Program

This may include public or private school, homeschool, early intervention or early childhood special education, transition programs, vocational training, or other individualized learning programs.
Name of Child/Youth's Learning Program
Organization/Program/School Name
Location of Child/Youth's Learning Program
Location/City
Financial Need
The Zetosch Fund is intended to support children and youth experiencing financial need. Does this child/youth's family need financial assistance to obtain the requested item or service?
Please explain:

Requested Funding
What are you requesting funding for? Please briefly list each item/service and its cost separately.
Total Cost
Please upload a separate document containing as much detail as possible on what you are requesting.

This document should include details such as model or product numbers, descriptions, features, vendor or provider names, costs, website links, as well as additional supporting documentation including vendor quotes, estimates, invoices, or photos that will help us understand each requested item or service and determine funding.
Cancelof
Where do you want the item(s) shipped? (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Who should we contact about this application?

Please tell us who we should contact about this application. We will use the email address(es) of the selected individual(s) to confirm receipt of the application, request additional information if needed, and share updates about the application.
Who should we contact about this application?

Other
Acknowledgement and Use of Information
By submitting this application, I confirm that the information provided is accurate to the best of my knowledge. I understand that submitting an application does not guarantee funding. I understand that UCP Oregon will keep records related to this application and may use this information to administer the Zetosch Fund, track funding history, understand who the Fund serves, and improve Family Support services.

Personal information will not be shared outside of UCP Oregon except as needed to administer the Fund. This may include contacting vendors, service providers, or other organizations identified in the application to verify requested items or services, confirm costs, and purchase, deliver, or arrange payment for approved items or services. UCP Oregon will make reasonable efforts to limit information shared to what is necessary for these purposes.

If this application or information is being submitted on behalf of the child or youth by someone other than the parent/guardian, I confirm that I have the family's permission to provide their information to UCP Oregon and to communicate with UCP Oregon regarding this request.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Welcome to the UCP Oregon Zetosch Fund Application Form.

Who is completing this application?

Child/Youth Applicant Information

Primary Contact Information

Educational, Vocational, Transition, or Other Learning Program

Financial Need

Requested Funding

Supporting Letter

Who should we contact about this application?

Acknowledgement and Use of Information