NCCDD:Jean Wolff-Rossi Fund for Participant Involvement (Rossi Fund) Application Form

Jean Wolff-Rossi Fund for Participant Involvement (Rossi Fund) Application Form

(ONLY ONE NAME PER APPLICATION)

This online application requires a contact e-mail as your official signature. If you do not have a contact e-mail, download the form (word or pdf format), print and complete it, and fax or mail it to the address at the bottom of the form*. If you need assistance, please contact 1-800-357-6916 or e-mail the Rossi Fund Coordinator at RossiFund@nccdd.org. If you do not receive an email from the Rossi Fund Coordinator acknowledging receipt of your application in 5 days of this submittal, please email RossiFund@nccdd.org or call 800-357-6916. All information provided is treated as confidential and only used for NCCDD internal Rossi Fund recordkeeping.

Please note: Rossi funds for the Autism Society of NC Annual Conference, March 30-31, 2012 have been allocated. No additional funds will be made available for this conference.

Please review the Jean Wolff-Rossi Fund for Participant Involvement Guidelines before completing this application.

Name (required):

Today's Date:

Address Line 1 (required):
Address Line 2:

City (required):

, NC

Zip (required):

Phone:
Home/Cell (required):
Work:

Disability Connection (required): To meet the criteria for receiving Participant Involvement Funds it is essential that the following information is completed: (Incomplete applications may be returned to applicants for completion.) (Check all that apply):
	I am a person with a developmental disability (see definition of Developmental Disability)
	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

Ethnic Status (optional)
	Hispanic	AfricanAmerican
	AsianAmerican	AmericanIndian
	Caucasian	Other

Event you plan to attend and seek financial assistance (required):

Event:

Location:

Event Date:

Give us detailed information about the event**:

Here is the Internet link:

I will mail/fax:

Have you attended this event before?

If Yes, when did you last attend this event?

Date:

Have you used the Rossi Fund (formerly Participant Involvement Fund) before?

If Yes, for what event?
When?
Amount received: $

Statement of Purpose (required): Please write a brief statement explaining your goals related to this particular event. Answer these three questions:
1. What is it you hope to learn/achieve by attending?
2. What will you do with the information you receive at this event?
3. How will you share the information with others in your community?

Financial Assistance is Needed For (required):
The Jean Wolff-Rossi Fund for Participant Involvement (Rossi Fund) can only partially fund the cost of attending an event. Rossi Funds are available to reimburse individuals for the types of expenses listed below (individuals may apply for funds to cover up to 3 of these expense categories).

Please indicate the amount of funds you are requesting – you may apply for funds from up to 3 of the expense categories listed below:

Check up to 3	EXPENSE Categories	Rossi Funds Requested	Notes
	Registration	$
	Hotel/Lodging	$	# of nights x $ per night (up to $65.90 plus tax in-state; $78.05 plus tax out of state)
	Transportation (List estimated mileage or other type of transportation - bus, train, etc.)	$	From (city, state): To (city, state): Round-trip mileage x $0.50/mile or other transportation (type):
	Respite/Child Care	$	# of hours x $ days x $8/hr. (max. $170/day)
	Personal Assistance	$	# of hours x $ days x $8/hr. (max. $170/day)
Total*		$

I have read and believe that I meet the criteria of the guidelines for reimbursement, meet the stated definition of developmental disability, completed this application with all required information, and attached an event brochure that provides description, agenda/schedule and registration form for the event.

This online application requires a contact e-mail as your official signature.
Enter your contact e-mail address:

We suggest that you keep a record of this application. Print a copy of the form before you submit the application, since each form is cleared after being submitted.

SUBMIT FORM (form will clear with each submission)

DISCLAIMER:
The Jean Wolff-Rossi Participant Fund for Participant Involvement is not an entitlement. The Rossi Fund Advisory Committee reserves the right to use discretionary judgment on any application they deem appropriate. Funds will be distributed consistent with the Council’s mandate in Federal Law for commitment to systems change, advocacy building, and capacity building.

*Incomplete applications may be returned to applicants for completion.

**DO NOT SUBMIT WITHOUT ATTACHING THE OFFICIAL BROCHURE WITH EVENT DESCRIPTION, AGENDA/SCHEDULE, AND REGISTRATION FORM OR THE SAME INFORMATION COPIED OR LINKED FROM THE OFFICIAL EVENT WEB PAGE/SITE.

Proof of submission: You will not receive an automated return e-mail to confirm your submission due to Internet security concerns. If you have not heard from the Rossi Fund in three days, please give us a call.

Mail or fax to:	Rossi Fund Coordinator NC Council on Developmental Disabilities 3125 Poplarwood Court, Suite 200 Raleigh, NC 27604
Email:	RossiFund@nccdd.org
(Voice/TDD): (Toll Free): FAX:	919-850-2901 1-800-357-6916 (919) 850-2915