Family Assistance Scholarship Program – Down Syndrome Association of the Upstate

Parent/Caregiver First Name *

Parent/Caregiver Last Name *

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Are you currently enrolled in a DSAU membership? *YesNo

Individual with Down Syndrome Name *

Individual with Down Syndrome Birthdate *

Scholarship Amount being applied for: *The maximum award is $500 per family, per calendar year. Families with more than one member with Down syndrome may submit applications for each child, for a maximum of $1,000 per year.

Please describe how the funds will be used (therapy, medical need, educational tool, recreational activity, etc) ? *(The Scholarship Committee may request additional information)

Please briefly explain your current situation and why these funds are needed at this time. *How will your child with Down Syndrome benefit from this purchase?

Proof of Down Syndrome diagnosis.(letter from physician or therapist, page from a medical or therapy record, mychart screenshot, or medicaid document)

No file chosen

Who should a check be made out to? *

What is your venmo handle should funds be transferred electronically?

If applicable, please provide any supporting documentation for reimbursement.Please provide copies of all associated receipts with the application. Include associated costs including actual cost of item or service, taxes, and shipping. This should include: invoices, service quotes, receipts, etc.

No file chosen

If this is a service you are applying for the scholarship to fund please provide the invoice here.

No file chosen

Vendor/service provider

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Vendor/Service Provider Email Address

Vendor/Service Provider Phone

Vendor/Service Provider Website

Signature *By signing below, I certify that the information provided is true and accurate to the best of my knowledge. I understand that funds are limited and that submitting an application does not guarantee funding. Approval of application and receipt of funding could take up to 45 days. We cannot guarantee funds will be provided prior to the start of requested program or services.