Test Application Use this form to apply for funding in St. Louis City Participant Name(Required) Address: Street, City, State, Zip Code(Required) Participant Phone Number(Required) Email (Participant or Best Contact Person)(Required) Add my Email address to...(Required) Weekly Email Newsletter Seasonal Newsletter only (3-4 times per year) Do not add my email to your lists Participant Living Situation(Required) Natural Home with Parent or Guardian Supported Living Foster Placement Independently Living Other Guardianship(Required) Participant is his/her own guardian. (Participant signs application) Someone else is participant's Guardian (Legal Guardian signs application) Parent or Guardian Name Parent or Guardian Address (if different from above) Social Security Number(Required) DMH case number Case Management(Required) Regional Office (Department of Mental Health) DDR Case Manager I do not have a case manager Case Manager Name, Email, and Phone Number (if applicable)Participant's Intellectual / Developmental Disability(Required) Participant is(Required) New Applicant - has never applied for funds in the past Returning Applicant Unknown New Applicants MUST complete eligibility form Find form at www.recreationcouncil.org/applications Name of Best Person to Contact Regarding this Application:(Required) Email Address for Best Person to Contact(Required) I hereby give the Recreation Council permission to verify participant’s eligibility by contacting the above listed eligibility verifier and permission to correspond with the program provider or support provider, our funding partners, Productive Living Board for St. Louis County Citizens with Developmental Disabilities (PLB); St. Louis Office for DD Resources, DDRB of St. Charles County, regarding funding issues, and/or other providers involved in which the voucher will be used. I understand my client rights and responsibilities and am aware of the Recreation Council Grievance Policies. Furthermore, I have read and understand the intent, purpose and guidelines of the Recreation Council voucher program for which the participant has applied. To the fullest extent permitted by law, I shall indemnify and hold harmless the Recreation Council of Greater St. Louis and its Directors, Officers, consultants, agents, employees and volunteers from and against any and all claims, damages, losses and expenses, including but not limited to attorney fees and court costs, arising out of or resulting from the provision of any service, provided that such claim, damage, loss or expense is attributable to bodily injury, sickness, disease or death, or personal injury, or to injury to or destruction of tangible property, which is caused in whole or in part by any acts, omissions or negligence of the service provider. I understand that the Recreation Council of Greater St. Louis is merely acting in the capacity of reimbursing the service provider of my own choice. Lastly, I understand that falsification of any of the information provided in this application and /or billing can and will be cause for disqualification from this program and all Recreation Council programs. With any electronic signature to this form, I agree that I am my own guardian or I am the applicant's legal guardian.(Required) Δ
