In Home Family Supports Application

Please complete and submit the entire application. Incomplete applications will not be considered. Please direct all questions to familysupportsgrant@thearcccr.org.

Parent/Legal Guardian Name*

Email*

Phone*

Phone

Street Address*

Address Line 2

City*

State*

Zip Code*

I live in...*

Select or enter value

I received funding for in-home family supports in the fall.*

Select or enter value

Child(ren) Name*

Child(ren) Age*

Please describe your child's disability.*

Please describe how your request is due to a change in circumstances from COVID-19.*

Please provide an in-depth explanation. Grants with little or no information will not be considered. This grant is intended to support a family's change in circumstance due to COVID-19.

Please list total cost of the service you are requesting.*

Example: 20 hours of babysitting at $20 per hour, for a total cost of $400.

Do you have a person/company currently selected for services?*

Yes

If you answered yes above, who is the provider you plan to use?*

Please note: If you select a family member, you will be contacted by the committee to confirm your request is eligible. The grant cannot be used to pay anyone living in the household where the family receiving services lives.

Select or enter value

How did you hear about us?*

Please list any additional information The Arc should be aware of while considering your request.

Send me a copy of my responses

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