Applicant's Name *

First Name

Last Name

Applicant's Date of Birth

MM

DD

YYYY

Applicant's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Applicant's Phone *

(###)

###

####

--For Adult Applicants: Have you been diagnosed with an intellectual developmental disability? --For Children/Family Applicants: Does the child have an IEP or recieve Special Education services in school? *

Yes

No

Submitter's Name

First Name

Last Name

Submitter's Phone

(###)

###

####

Which of the following would a community grant from the ACL help you with? *

Check all that apply

Home/Housing

Employment

Education and Learning

Transportation

Social Life

Community Engagement

Hobbies and Interests

Safety

Healthy Lifestyle

Future Planning

Building Relationships

Other