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

(ONLY ONE NAME PER APPLICATION)

EFFECTIVE July 1, 2017: An application must be received by NCCDD 15 days prior to the first day of an in-state event and 30 days prior to first date of an out-of-state event. Applications are funded on a first-come, first-served basis. The NCCDD reviews applications frequently, and the decisions on all applications will be mailed in writing to all applicants.

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

Customer Information

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Please specify your email address.

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Disability Connection (required):

To meet the criteria for receiving funds from the Jean Wolff-Rossi Fund for Participant Involvement it is essential that the following information is completed. (Incomplete applications may be returned to applicants for completion.)

(Check all that apply):

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Ethnic Status (optional)

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Event You Plan to Attend and Seek Financial Assistance: (NOTE: With this application, you MUST submit the Official brochure with event description, agenda/schedule, and registration form or the same information copied from the official event website.)

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Event Start Date:
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Event End Date:
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Statement of Purpose:

In the space provided below, please write a brief statement explaining your goals related to this particular event.
Answer these three questions:

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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 Rossi Funds Requested Notes
Registration $ The Rossi Fund will only pay the “early bird” registration fee rate.
Hotel/Lodging $ # of nights  x $ per night (up to $71.20 plus tax in-state; $84.10 plus tax out of state)
Transportation
(List estimated mileage cost or other type of
transportation
- bus, train, etc.)
$ From (city, state): 

To (city, state):


Round-trip mileage x 53.5 cents/mile (under 100 miles)
Round-trip mileage x 17 cents/mile (over 100 miles)
or other transportation (type):
Respite/Child Care $ # of hours  x $ days x $8/hr. (max. $170/day)
Personal Attendant Services $ # of hours  x $ days x $8/hr. (max. $170/day)
Total* $

I have read and meet the criteria of the guidelines, meet the definition of developmental disability given, and completed this application with all information requested. I have also enclosed the official brochure with event description, agenda/schedule and registration form or the same information copied from the official event web page/site.

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SUBMIT FORM (form will clear with each submission)

DISCLAIMER:
The Jean Wolff-Rossi Fund for Participant Involvement (Rossi Fund) is not an entitlement. NCCDD 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, and capacity building.

*Incomplete applications may be returned to applicants for completion.

**DO NOT SUBMIT WITHOUT PROVIDING WEB PAGE/SITE LINK TO THE OFFICIAL EVENT SITE WHICH SUPPORTS ACCESS TO EVENT DESCRIPTION, AGENDA/SCHEDULE, AND REGISTRATION FORM.**.

EMAIL, MAIL, OR FAX TO:
Jean Wolff-Rossi Fund for Participant Involvement
NC Council on Developmental Disabilities
3125 Poplarwood Court, Suite 200
Raleigh, NC 27604
Email: RossiFund@nccdd.org
(Voice/TDD) (919) 850-2901
(Toll Free Voice/TDD) (800) 357-6916
(FAX) (919) 850-2915

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North Carolina Council on Developmental Disabilities
3125 Poplarwood Court
Suite 200
Raleigh, NC 27604
Info@nccdd.org
919-850-2901 (voice/tdd)
800-357-6916 (voice/tdd)
800-357-6916 (TTY)
919-850-2915 fax