PWSA of WI, Inc.
APPLICATION FOR GENERAL ASSISTANCE SCHOLARSHIP
PURPOSE:
PWSA of WI, Inc. wishes to provide financial assistance for families of an
individual with PWS to help meet the unique needs of these individuals and
their families.
ELIGIBILITY:
Eligibility is based on financial need of the person with PWS. Financial
need being equal, the second consideration would be given to those who could
benefit most from attendance (respite intervention or personal/behavioral
issues that need to be addressed).
1. Any person with PWS who resides in the state of WI.
2. The person with PWS or the caregiver or a family member of the person
with PWS must be a member of the state chapter of the PWSA of WI, Inc.
Date of request_______________
Name of person w/ PWS:____________________________________ Sex_______
Birth date____________
Address_________________________City________________State______ZipCode___________
Phone (_______)________________________Does individual reside in
WI? _____Yes _____No
Contact person__________________________ Phone
(_______)_________________________
Is individual, family member or caregiver a member of PWSA of WI, Inc.?
______Yes ______No
Specific dates funds are needed by: ______________________ Amount
Requested: _________
What will funds be used for?
_______________________________________________________________
Why would this scholarship be helpful to you? How will funds improve the
quality of life for the individual with PWS? (Financial need, need
for respite, etc.) Use reverse side or attach additional paper if needed.
Send application to:
PWSA of WI, Inc.
2701 N. Alexander St.
Appleton, WI 54911