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2018 Stipend Request Form

Type of Stipend you are applyling for:Recreational Educational

Have you received a stipend from us before? Yes / No*
If yes, when was the last stipend received?
Date Received in Office
Please indicate your volunteer hours at fundraisers/events, activities, at office in last 12 months:
Total Volunteer Hours:* State # of hours per event:
Walk For Hope Fall Membership Meeting/Picnic Trivia Night Holiday Party Seminar At Office Other(description of other )
Note: You MUST be an active member to qualify for a stipend. Hours will be verified.
Please indicate your relationship to the individual with disability:
Self/Parent/Caregiver/Other (please specify)*
OR
Note: An application may or may not be funded dependent on the number of applications received and the amount of funding available for the type of stipend program.
Please read and sign stipend guidelines PRIOR to submittal and make sure ALL documentation is attached.
For Office Use Only
Amount Approved: ____________________
Notified: Parent (date) _________by mail/email/phone & Provider (date) ________ by mail/email/phone