Goldberger Family Endowment Fund for Children with Special Needs

Goldberger Family Endowment Fund for Children with Special Needs
This fund provides financial support for Jewish families in greater St. Paul whose children (age 12 months to 18 years) are medically diagnosed with developmental disabilities, learning disabilities, or special healthcare needs. Distributions are based on family needs and income and can be applied for at any time of year. Funds can be used for:
- Jewish educational support at St. Paul beneficiary agencies and synagogues
- Recreational programs
- Equipment
- Specialty camps
- Summer camps
- Educational programs
If you have any questions about how to fill out the application or about the program, please get in touch with Ellen Konstan at ekonstan@stpaulfed.org

FAMILY INFORMATION
Parent/Guardian*

First NameLast Name
Preferred phone number*
Please enter a valid phone number.
Email*
example@example.com
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Total Family Income:*
Number of people in the household:*
Number of dependent children:*

CHILD INFORMATION
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Current School*
Current Grade*
Child's Diagnosis*
Diagnosis Date*

MonthDayYear
Date
If you have a current IEP, please attach in the box below.

The committee reserves the right to request medical/psychological evaluation if more information is needed.
Cancelof

PROGRAM INFORMATION
Please describe the program or equipment you are applying for:*
(including name, purpose, duration, and website if available)
Program Cost*
Why will this be beneficial to your child?*
Have you applied for scholarship assistance from other sources? If yes, please list organizations, amount applied for, and amount awarded (if known.)
Please attach any supporting documentation describing the program or item you wish to have funded, such as a recommendation for your child or about the program.

Cancelof
Special Circumstances
Please list other children with diagnosed special needs in the home, other health concerns, and/or other extenuating circumstances relevant to this application:
Are you applying for any additional children?*
ADDITIONAL APPLICATION
Additional Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Current School*
Current Grade*
Child's Diagnosis*
Diagnosis Date*

MonthDayYear
Date
Please attach current IEP.*

The committee reserves the right to request medical/psychological evaluation if more information is needed.
Cancelof
PROGRAM INFORMATION
Please describe the program or equipment you are applying for:*
(including name, purpose, duration, and website if available)
Program Cost*
Why will this be beneficial to your child?*
Have you applied for scholarship assistance from other sources? If yes, please list organizations, amount applied for, and amount awarded (if known.)
Please attach any supporting documentation describing the program or item you wish to have funded, such as a recommendation for your child or about the program.

Cancelof
Signature*

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Goldberger Family Endowment Fund for Children with Special Needs

Special Circumstances

ADDITIONAL APPLICATION

PROGRAM INFORMATION