United Cerebral Palsy of Prince George's and Montgomery Counties

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UNITED CEREBRAL PALSY OF PRINCE GEORGE’S AND MONTGOMERY COUNTIES Wm. Irwin Buck Center 4409 Forbes Blvd. Lanham, Maryland 20706 (301) 459-0566 (301) 459-7691 FAX (301) 459-7691 TDD/TT

TOMMY MARSHALL MEMORIAL FUND
2008 Funding Award Application


Please print this application to fill out and submit it by mail to the United Cerebral Palsy of Prince George's and Montgomery County by JUNE 30, 2008.

Applicant Name:
Address:
City, State, Zip:
Phone:
Fax:


Email:
County:
Birthdate:
If under 18, name of parent(s) and/or legal guardian:

If no, please provide address and phone number:
Phone:

If applicant is not the primary contact, please complete the following information:

Contact Name:
Organization/School/Business (if applicable):
Title (if applicable):
Address:
City, State, Zip:
Phone:
Fax:
Email:

Relationship to Applicant:	Parent Teacher Employer Friend Family Member Other


SERVICES/ASSISTANCE INFORMATION
What type(s) of disabilities does the applicant have for which he/she is seeking financial assistance? Does the applicant currently receive disability- related services associated with this request? Yes No If yes, please describe the services received, as well as the location, frequency and the setting in which they are provided. (Please attach additional pages if necessary.) Have there been attempts to secure funding for the services, assistive technology and/or equipment through private insurance and/or public funding streams? Yes No If yes, please describe attempts. (Please attach additional pages if necessary.) FINANCIAL NEEDED: As stated, one of the eligibility requirements for this award is the ability to demonstrate financial need. Please share below a brief synopsis of how the applicant meets this requirement. Please include as little or as much information as you feel comfortable sharing that will effectively demonstrate financial need. (Attach additional pages if necessary.)

TESTIMONY OF ACCURACY

I hereby certify that the information contained in this application is correct. I understand the United Cerebral Palsy has the right to verify the information provided on the application and may require additional documentation to verify disability or income eligibility. I understand that should United Cerebral Palsy find any information contained in this application to be false, it may revoke any funding bestowed as a result of this application. Signature of applicant, parent or legal guardian: __________________________________ Date: ____________________ IMPORTANT NOTE: A personal letter from the applicant, parent or legal guardian to accompany the nomination form is also strongly recommended, but not required.
APPLICATION DEADLINE: JUNE 30, 2008 The application is to be received at the address below by this date. Deadline extensions will not be granted Please send the application to: The Tommy Marshall Memorial Fund United Cerebral Palsy of Prince George's and Montgomery Counties 4409 Forbes Blvd Lanham, Maryland 20706 If you have any questions about this application, please call (301) 459-0566 (ext. 12) or email us at ucppgmc@ucppgmc.com.

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