ADVOCATE PRESCREEN

1
Name* This field is required.What is your first and last name?
First Name
Last Name
2
Email* This field is required.What is your email address?
example@example.com
3
Have you ever received a grant from Special Education Legal Fund for THIS STUDENT?* This field is required.If you have previously received an ADVOCATE GRANT (Advocacy Support Program) for this student, you are not eligible to reapply for this program. You may, however, potentially apply for the ATTORNEY GRANT should your case require an attorney's intervention. If you have previously received ANY S.E.L.F. GRANT for this student, you are not eligible to apply for an ADVOCATE GRANT. If you have received either type of grant for another student in your family, you may apply again to this program for the new student.
YESNO
4
Does THIS STUDENT Have a Current IEP (Individualized Education Plan) or 504 Plan?* This field is required.A current IEP (Individualized Education Plan) or 504 Plan a requirement of this program.
YESNO
5
What School District Do You Live In?* This field is required.PLEASE SELECT FROM THE DROP DOWN MENU.
Andover
Ansonia
Asford
Avon
Barkhamsted
Berlin
Bethany
Bethel
Bloomfield
Bolton
Bozrah
Branford
Bridgeport
Bristol
Brookfield
Brooklyn
Canaan
Canterbury
Canton
Chaplin
Chesire
Chester
Clinton
Colchester
Colebrook
Columbia
Cornwall
Coventry
Cromwell
Danbury
Darien
Deep River
Derby
East Granby
East Haddam
East Hampton
East Hartford
East Haven
East Lyme
East Windsor
Eastford
Easton
Ellington
Enfield
Essex
Farfield
Farmington
Franklin
Glastonbury
Granby
Greenwich
Griswold
Groton
Guilford
Hamden
Hampton
Hartford
Hartland
Hebron
Kent
Killingly
Lebanon
Ledyard
Lisbon
Litchfield
Madison
Manchester
Mansfield
Marlborough
Meriden
Middletown
Milford
Monroe
Montville
Naugatuck
New Britain
New Canaan
New Fairfield
New Hartford
New Haven
New London
New Milford
Newington
Newtown
Norfold
North Branford
North Canaan
North Haven
North Stonington
Norwalk
Norwich
Old Saybrook
Orange
Oxford
Plainfield
Plainville
Plymouth
Pomfret
Portland
Preston
Putnam
Redding
Region 1
Region 4
Region 5
Region 6
Region 7
Region 8
Region 9
Region 10
Region 11
Region 12
Region 13
Region 14
Region 15
Region 16
Region 17
Region 18
Region 19
Ridgefield
Rocky Hill
Salem
Salisbury
Scotland
Seymour
Sharon
Shelton
Sherman
Simsbury
Somers
South Windsor
Southington
Sprague
Stafford
Stamford
Sterling
Stonington
Stratford
Suffield
The Gilbert School District
The Woodstock Academy Public Schools
Thomaston
Thompson
Tolland
Torrington
Trumbull
Union
Vernon
Voluntown
Wallingford
Waterbury
Waterford
Watertown
West Hartford
West Haven
Westbrook
Weston
Westport
Wethersfield
Willington
Wilton
Winchester
Windham
Windsor Locks
Windsor
Wolcott
Woodbridge
6
What was your last reported adjusted gross income?* This field is required.From your most recent tax return. If you do not file taxes, please select "Not Applicable/No Reported income."
$10,000 or below
$10,000-$20,000
$20,000-$30,000
$30,000-$40,000
$40,000-$50,000
$50,000-$60,000
$60,000-$70,000
$70,000-$80,000
$80,000-$90,000
$90,000-100,000
$100,000-$110,000
$110,000-$120,000
Not Applicable/No Reported Income
More than $120,000
7
How Many People Live In Your Household?* This field is required.Including dependents listed on your most recent tax return.
2
3
4
5
6
7
8
More than 8
8
What is your goal with this action? DO NOT REPLY "BECAUSE I CANNOT AFFORD AN ADVOCATE."* This field is required.Please summarize the goal you wish to achieve for your student should you receive a grant for advocacy support. Please do not include a statement of financial hardship or need.
Huge
Large
Normal
Small
Ok
Ok
9
Tags
Todo
In Progress
Done
Should be Empty: