You must have JavaScript enabled to use this form. Do you have proof that you are a resident of Lancaster County? Yes No Do you have and would you be able to provide proof of an Intellectual Disability by a medical professional? Yes No Full Form Person Needing Assistance Full Name Developmental/Intellectual Disability Diagnosis Person Completing this Form Your Name Phone Email Address Your Address Address City/Town State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP Code Assistance Requested Please describe the financial need for assistance. Please describe other sources you have approached for assistance. Please list the individual's sources and amounts of current income. Services Received Residential Service Received Day Service Received Service Coordinator Amount Requested How much are you requesting? $ Will this be a grant or a loan? This will be a grant This will be a loan What is the plan for loan repayment? How would you like to receive the payment? Visa Gift Card Check Where should the check be made out to? (Checks payable only to place of purchase, and cannot be made out to individuals) Please provide a name and phone of who the gift card will b e sent to. Address to send the payment/Visa Gift Card? Address City/Town State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP Code Phone Number All requests are reviewed electronically on an as needed basis. Please give a timeline when making vacation requests. Please note that all approved requests sundown six months after they are approved unless otherwise stated. The Foundation Policies and Procedures are also available upon request. For additional information please go to the contact portion of the homepage to contact the foundation. All information obtained from this form will only be used for Quality of Life Foundation grant purposes.