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Family Support

Discretionary Fund Application

Date of Request:
GCS Eligible Participant:
Name of Person Requesting Funds:
Address:
City, State, ZIP    
Best Phone Number to Use:
Best E-mail Address to Use:
Amount Requested:
In answering the following questions, please include the following information: number of individuals involved, nature of activity, date, time and place of activity, is this something that Gateways Community Services could share with other families receiving services, and any other information that would be helpful in understanding your request.

Reason for request:

How will this benefit the individual/family?

Other Funding
Please list any other sources of funding you are currently utilizing, have accessed in the past, or have applied for: (Harry Alan Greg, Mini TASH, School, etc.)


Contact Person and Address where funds should be sent upon approval:

Check this box if this is a reimbursement
Contact Person:
Address:
City, State, ZIP    


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