Consumer Involvement Fund Application Form

Name: ______________________________

Date: _______________________________

Address: __________________________________________________

City: _______________________________

Zip: _________________

Phone: H: ____________ W: ___________

E-mail address ______________________

Check which applies:

______ I am a person with a developmental disability.

______ My family member is an adult with a developmental disability. (The term family is used to refer to children and their parent(s) or family member(s) who are primary caregivers)

______ I am a parent of a child with a developmental disability.

______I am the guardian for a person with a developmental disability.

_______ Age of individual with a developmental disability.

List Activity For Which You Are Seeking Funds To Attend:

(You must attach to this application any printed information on the event that clearly explains what you want to attend, such as the agenda, brochure, and registration form).

How Will You Share Your Information? :

Activity/Event Date(s): ____________________________

Location: __________________________________

Have You Attended This Activity Before? _______ Yes ________ No

If Yes, When Did You Last Attend This Event? Date: ____________________________

Have You Used the Consumer Involvement Fund Before? _______ Yes ______No

If Yes, For What Event? _______________________________________

and When? Date: _______________________

Amount Received $ ________________________

Ethnic Status (optional)

______ Hispanic

______ African-American

______ Asian-American

______ American Indian

______ Caucasian

______ Other

I agree to be a resource person for other consumers, parents, and family members of individuals with disabilities. _________Yes _________No

FINANCIAL ASSISTANCE IS NEEDED FOR:

(Please indicate how much you can pay, how much you can get from other sources and how much you are requesting from the Consumer Involvement Fund)

MAIL OR FAX TO:
ACDD/CIF
100 North Union Street
Post Office Box 301410
Montgomery, Alabama 36130-1410

FAX: 334-242-0797

PHONE: 1-800-232-2158