APPLICATION FORM FOR THE PARTICIPANT INVOLVEMENT FUND (PIF)

Each person requesting funds must fill out an application. One name per application, please. 

If you need assistance completing this application, please contact 1-800-357-6916.

*The term ''developmental disability'' means a severe, chronic disability of an individual that:

• is attributable to a mental or physical impairment or combination of mental and physical impairments;

• is manifested before the individual attains age 22;

• is likely to continue indefinitely;

• results in substantial functional limitations in 3 or more of the following areas of major life activity:
  1.  Self-care.
  2.  Receptive and expressive language.
  3.  Learning.
  4.  Mobility.
  5.  Self-direction.
  6.  Capacity for independent living.
  7.  Economic self-sufficiency. and;

• reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated.

Check the box that applies:
         I am a person with a developmental disability (see definition*)
         My family member is an adult with a developmental disability
         I am the parent of a child with a developmental disability

         I am parent of a child at risk of a developmental disability
         I am the individual guardian for a person with a developmental disability

       Age of individual with developmental disability

Today's date:  

Applicant

First Name:     MI:        Last Name:     

Social Security No: 

Address

Address Line 1:  

Address Line 2: 

City:      State:     Zip Code:  

Home Phone:     Work Phone:   

To meet the criteria for receiving Participant Involvement Funds, it is essential that the following information is completed: (Incomplete applications will be returned to applicants.)

1.  Ethnic Status (optional)
       African American
       American Indian
       Asian American
       Caucasian 
       Hispanic
       Other   

2.  Information about the event for which you are seeking funds to attend:

You must submit with this application information about the event that clearly explains what you want to attend, such as the agenda, a brochure and/or registration form.  Submit this information via email to the PIF Coordinator , fax (919-420-7917), or by mail to the address below. If the information is available from the event's website,  you can email the web page containing the information to the PIF Coordinator.

     Name of the Activity/Event:
     Event Date: 
     Location: 
     Have You Attended This Event Before? YES NO
     If Yes, when did you last attend this event?  Date: 

Statement of  Purpose:

Please write a brief statement explaining your goals related to this  particular event.  What is it that you hope to learn/achieve by attending, and how might this benefit you? (you may add the website containing information about the event)
                                     
 

3.  Have you used the Participant Involvement Fund before?  YES NO
If Yes, please give event name  , event date , 

and the amount of funds you received from the Participant Involvement Fund $

4.  Financial Assistance Requested:

 
Please indicate how much you can pay, how much you can get from other sources and how much you are requesting from the Participant Involvement Fund. 
                                      

Disclaimer:   The Participant Involvement Fund (PIF) is not an entitlement.  The PIF committee reserves the right to use discretionary judgment on any application they deem appropriate.

I have read and meet the criteria of the guidelines, meet the definition of developmental disability given, completed this application with all information requested and have enclosed an event brochure and/or web address about the event.

As my signature affirming this statement, I enter my email address (if no email, type full name)

Your email address/Full Name: