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CDA Financial Assistance Application
Financial Assistance Request
Participant Name
*
First Name
Last Name
Age
*
Phone
*
Email
*
Verify Email
*
Participant's Veteran Status
*
Yes
No
Employment
*
Is the participant employed?
select one
Yes
No
Organization/Employer
Income
*
Please enter the yearly income for your household
Is the participant on Public Assistance?
*
select one
Yes
No
Does the participant receive any of the following benefits?
*
Please Select all that apply.
Social Security
SSDI
Medicaid
Medicare
Other
Name of Legal Guardian (if Applicable)
First Name
Last Name
Legal Guardian's Phone
Is Parent/Guardian/Caregiver Employed
*
Select "Not Applicable" if you are the participant
select one
Yes
No
Not Applicable
Is the Parent/Guardian/Caregiver on public assistance?
*
Select "Not Applicable" if you are the Participant
select one
Yes
No
Not Applicable
Does the Parent/Guardian/Caregiver receive any of the following benefits?
*
Please Select all that apply.
Social Security
SSDI
Medicaid
Medicare
Other
Not Applicable
Does the Participant or Parent/Guardian rent or own home?
*
select one
Own
Rent
Other
Number of people in household:
*
select one
1
2
3
4
5
6
7
8
9 or more
Financial Assistance Request Statement
*
Colorado Discover Ability (CDA) is a non-profit organization and has limits on funding available for financial assistance. We strongly encourage participants to pay as much as they are able so that assistance will be available to others throughout the year. Our financial assistance is now provided on a sliding scale based on income. Because we have received some grant money allocated specifically for this purpose, our funders have requested that we collect the following information from you. All of the information requested is for CDA use only and will remain confidential, unless required to be reported as part of the grant. Please tell us how this assistance will help you achieve your goals.
Our funders ask us to share what has changed because to this experience
*
We occasionally ask our recipients to write letters of support about our organization, which we use in our grant reports, marketing materials, or donation solicitations. (You can determine whether or not we use your name) Would you be willing to write a letter of support?
select one
Yes
No
Maybe
