* = required fields

Name(s): *

Address: *
City: *
State: *
Zip code: *
Daytime phone: *
Email address: *
Full name of child/person with special needs: *
Age of child/person with special needs: *
Your relationship to the child/person with special needs: *
Activity you are planning to attend or requested service or item: *
            If conference or class please fill in:
            Activity date:     
            Activity location:
How will this request benefit the child/person with special needs? *
Have you used the DSAW Member Grant program before? *
Yes   No
      If yes, when: 
Have you requested support from any other source? *
Yes   No
      If yes, what source(s):
Total cost for the conference, program, course, service or item: *
Amount you are requesting from the DSAW Member Grant program: *

We must receive your application at least 30 days prior to the first day of the event.

Please double-check this form for accuracy before submitting.

 


 
 

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