The Frances Hicks Memorial Fund: FUNDING REQUEST FORM
Qualifying Criteria:
Individuals with an intellectual disability (70 IQ or below) or programs serving this
population.
Must be unable to obtain sufficient funds from other sources.
The services funded are not the obligation of public school, social service agency,
insurance policy, or any other organization.
Recipient must be a resident of Windham County, VT or Cheshire County,NH
The Frances Hicks Board meets four times yearly. These requests MUST be postmarked by the followings dates to be considered. CHECK ONE
August 15 _______ November 15 _______ February 15 _______ May 15 _____
1. Name of person receiving funding____________________________________ Age of recipient ________________ Town of residence___________________ County __________________________ Date _____________________________
2. Please provide documentation that establishes an intellectual disability if not previously submitted. (e.g., cognitive test results, IEP, 3 year evaluation)
3. Describe why the funding is needed and/or what it will be used for? Describe the program, organization or person providing the service. If applicable, attach a pamphlet.
4. TOTAL AMOUNT REQUESTED $_____________ Fill out below if it applies: _________ lessons at $____________ each; From date __________ to __________ 5. Are there other organizations you can ask for help?
6. The amount of funding depends upon money and the number of requests submitted. Will partial funding be helpful? How much could you contribute?
Revised 1/2021
8. Who filled out this form? Please provide all contact information.
Name: ____________________________________________________________ Address: __________________________________________________________ Email:________________________________________ Phone: ______________
9. Service provided by:
Name:______________________________________________________________
Address:____________________________________________________________
Email:_________________________________ Phone: _____________________
10. If funding is granted, where should the check be sent? Checks are made payable to the provider/program only.
Name: _____________________________________________________________ Address: ___________________________________________________________
11. If funding is granted, the enclosed project report form must be completed and returned. Future requests will not be considered without its completion. Send to:
The Frances Hicks Memorial Fund
c/o Ms. Linda Tummino, Screening Committee Chair 30 Hillwinds North
Brattleboro, VT 05301
Questions? Contact Linda at ltumm@comcast.net, 802-257-4975 or Cal Heile, President, at 802-254-2196.
The Frances Hicks Memorial Fund Board is committed to safeguarding the personal information of all applicants. All information provided is confidential and only discussed within the confines of the board and/or with the applicant or applicant designee.
Revised 1/2021
Revised 1/2021