Consumer Stipend Funds Application

Basic Information

Today's Date*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

County*

Phone*

Email*

Answer the following questions:

Select the option that applies most*

I am a person with a developmental disability.
My family member is a person with a developmental disability
I am the guardian/foster parent of a person with a developmental disability.

My family member is my*

Son
Daughter
Other

Please describe other.*

Family Member's Name*

First Last

What is the developmental disability?*

Workshop / Conference Information

Please provide the name(s) and date(s) of birth (DOB) below of all family members attending the conference/workshop.

Name

First Last

Date of Birth

Do you have another family member attending?

Yes
No

Family Member's Name

First Last

Date of Birth

Do you have another family member attending?

Yes
No

Family Member's Name

First Last

Date of Birth

Do you have another family member attending?

Yes
No

Family Member's Name

First Last

Date of Birth

Do you have another family member attending?

Yes
No

Family Member's Name

First Last

Date of Birth

Name of conference/workshop you want to attend

Conference Location

Conference Date

Have you used the Consumer Stipend Project before?*

Yes
No

When?

For what conference?

Which of the following topics apply to your conference?

Check all that apply:

Enter amount of financial assistance needed below for each category. (Maximum award is $400 per person or $700 per family)

Registration

Attendant

Hotel

Transportation

Child Care

Respite Care

Meals

Total Costs

Attach Conference Brochure

Max. file size: 50 MB.

Attach Conference Registration Form

Max. file size: 50 MB.

The following statement must be signed to validate this request.

Agreement*

I am requesting assistance from The Arc of Illinois, through funding from the Illinois Council on Developmental Disabilities, to attend a conference that I would be unable to attend without this support. I promise to use the funds for the stated purposes and to submit receipts for all expenditures funded through this stipend. I will also complete a post-conference evaluation form.

I Agree

Authorized Electronic Signature

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