NCCDD - Jean Wolff-Rossi Fund for Participant Involvement Application Form

Please complete all required fields!

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

(ONLY ONE NAME PER APPLICATION.)

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

Name(*)

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Todays Date

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Address(*)

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City in NC(*)

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Zip(*)

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Email(*)

Please specify your email address.

Home/Cell Phone

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Work Phone

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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):

I am a person with a 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

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Ethnic Status (optional)

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(*)

Event You Plan to Attend and Seek Financial Assistance (required): (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.)

Event

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Location

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Website address about this event (if available):

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Have you attended this event before?

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Event Start Date:

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Event End Date:

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If Yes, when did you last attend this event?

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Have you used the Rossi Fund before?

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If Yes, for what event?

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When?

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Amount received: $

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(*)

Statement of Purpose (required):

In the space provided below, 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?

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2. What will you do with the information you receive at this event?

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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. There is a limit of $600 per year, per person, for in-state events and up to $800 per year, per person, for out-of-state events:

Check up to 3	EXPENSE Categories	Rossi Funds Requested	Notes
	Conference/seminar registration	$	The Rossi Fund will only pay the “early bird” registration fee rate.
	Hotel/Lodging	$	# of nights x $ per night (up to $98 plus tax in-state; $98 plus tax out-of-state)
	Transportation (List estimated mileage cost or other type of transportation - bus, train, etc.)	$	From (city, state): To (city, state): (65.5 cents/mile – NC State government rate is subject to change) Round-trip mileage x 65.5 cents/mile Round-trip mileage x 33 cents/mile (over 100 miles) or other transportation (type): Other Method of Travel Expected: Expected Cost Round-Trip of Travel Method: Other expenses are at the discretion of the NCCDD
	Respite/Child Care	$	# of hours x $ days x $15.60/hr. (max. $150/day)
	Personal Attendant Services	$	# of hours x $ days x $15.60/hr. (max. $150/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.**.

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

US MAIL:
NCCDD Rossi Fund
2010 Mail Service Center
Raleigh, NC 27699-2010

EMAIL: RossiFund@nccdd.org

FAX: 984.920.8201

PHONE: (919) 527-6500, (Toll Free Voice/TDD) 1-800-357-6916

North Carolina Council on Developmental Disabilities - NCCDD

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

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