Online Application

Recreation Council - Universal Voucher Funding Application

Use this form to apply for funding.

All About the Participant

County and Eligibility Info

NEW APPLICATIONS MUST CONTACT OUR OFFICE WITH THE FULL SOCIAL SECURITY NUMBER TO APPLY. THIS IS NOT OPTIONAL.

Participant Name(Required)

First Last

Name of child or adult attending the program.

Participant Lives in:(Required)

St. Louis County

St. Louis City

St. Charles County

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Address of PARTICIPANT. Parent address (if different) is entered below.

Does Participant Have an Intellectual / Developmental Disability?(Required)

Yes

Is this a New Address?(Required)

Yes

Please Specify Your Disability:

Participant DOB(Required)

Is the Participant New to the Recreation Council?(Required)

Yes

ST LOUIS CITY AND COUNTY residents: If you clicked "YES", you must submit a paper application with your SSN. Contact your area coordinator at 314-726-6044. This does not apply to St. Charles County residents.

Last 4 of SSN for Returning Applicants

Level of Support Needed:(Required)

1:1

1:4

1:8

Other

Participant Phone Number(Required)

DMH Number (required for St. Charles County residents)

Participant Email(Required)

Coordinator’s Name:

First Last

Casemanager Name - DDR, DDRB, PLB, DMH Service Coordinator

Participant Gender(Required)

Male

Female

Prefer not to say

Coordinator’s Phone Number:

Casemanager Phone- DDR, DDRB, PLB, DMH Service Coordinator

Would you like to be included on our email list for our newsletter, future voucher applications etc.?

Yes

Case Management(Required)

Regional Office (Department of Mental Health)

DDR, DDRB, PLB case manager

I do not have a case manager

I do not know

Is Participant under 18 Years of Age?(Required)

Yes

Who is the contact person to send notifications and answer questions regarding this application? IMPORTANT!

Parent Name

First Last

If no parent/foster parent is involved, enter N/A

Name:(Required)

First Last

Best Person to Contact if more information is needed to process this applicatrion.

Parent Address

Street Address City State / Province / Region ZIP / Postal Code

Address

Street Address City State / Province / Region ZIP / Postal Code

Best Person to Contact if more information is needed to process this applicatrion.

Parent Email

Parent Phone Number

Email(Required)

Best Person to Contact if more information is needed to process this applicatrion.

Legal Guardianship(Required)

Participant is his/her own guardian. (Participant signs application)

Someone else is participant's Guardian (Legal Guardian Must Sign Application)

Phone Number:(Required)

Best Person to Contact if more information is needed to process this applicatrion.

Guardian Email (If Self Still Enter)(Required)

Enter Email Confirm Email

LEGAL GUARDIAN is yourself, parent of minor children, or court-appointed Legal Guardian/public administrator.

Guardian Name

First Last

LEGAL GUARDIAN is yourself, parent of minor children, or court-appointed Legal Guardian/public administrator.

Guardian Phone Number

Guardian Address

Street Address City State / Province / Region ZIP / Postal Code

Legal Consent(Required)

I agree to the terms and conditions.

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.

Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures

Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.

You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below.

Scope of Consent
By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below.

Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies.

Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.

Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.

“Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.

“Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .

“Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.

The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.

Electronic Signature(Required)

The Recreation Council Voucher Programs

*FUNDING. The Recreation Council Voucher Funds are "Last Dollar In." Therefore, we strongly encourage you to inquire with the program you are applying for if they have financial assistance, scholarships, coupons, etc.
*REQUIRED. All information of this entire form must be fully completed to be considered eligible for voucher funds.
*FOLLOW UP. You will be receiving a survey from The Recreation Council. Completion of this survey determines future funding to our organization and these voucher programs. Please complete our surveys.

If you are applying for multiple vouchers, you must use a separate application for each program.
ALL INFORMATION ON THIS FORM MUST BE COMPLETED TO BE CONSIDERED FOR THE VOUCHER FUNDS!

Which voucher applying for?(Required)

Experiential Adventure Voucher

CARE (program) and Recreation Support Voucher

After School/Extended Day Voucher

Overnight Camp Voucher

Adventure=Adults ages 18 & older, trips, day adventures.....CARE=all ages, summer and break day camps, leisure programs, horseback, special interest classes, sports.....CARE/Recreation Support=all ages, personal care for toileting, feeding, dressing, behavior support at an inclusive program, family hires and pays caregiver......After School is only in St. Louis City and County.....Overnight Camp=all ages, week-long or 3-4 day overnight programs

Experiential Adventure Voucher

Recreation Program(Required)

Tell us what you are doing. Example: Branson Weekend Trip

Name of Recreation Provider(Required)

Tell us the name of the organization providing your adventure program.

Program Dates(Required)

You must have these dates to apply.

Contact Person(Required)

Who should we talk to at your program to set up the voucher?

Adventure Provider Telephone Number

Provider Email

Adventure Provider Address

Street Address City State / Province / Region ZIP / Postal Code

REQUEST:

Cost of Program: $(Required)

Your Co-Pay (at least 10%): $

Amount of Funds You are Able to Pay in Addition to the Co-Pay: $

Note any funding needs beyond standard voucher

Your Case Manager or Service Coordinator must verify your financial hardship if you cannot pay the required 10% co-pay.

Funding Request: $(Required)

Tell us how much funding you need to attend your adventure

Care and Recreation Support Voucher

I am applying for: (please check either and/or both)

CARE-Recreation Program Funds

Recreation Support Provider Hours

CARE=all ages, summer and break day camps, leisure programs, horseback, special interest classes, sports.....Recreation Support Provider Hours=all ages, personal care for toileting, feeding, dressing, behavior support at an inclusive program, family hires and pays caregiver.

Name of Program Attending:(Required)

Tell us the activity you are enrolling in. Examples: "Private swim lessons"; "day camp"; "piano lessons"

Name of Recreation Provider(Required)

Tell us the name of the organization providing your program.

Contact Person:(Required)

Who should we talk to at your program to set up the voucher?

Telephone Number:

Email Address:

Program Dates(Required)

START and END dates. For programs with multiple sessions, write in start/end dates for each session. If you do not know your exact start date, write "anticipated" and start/end dates. Funding is granted once dates are confirmed.

Address

Street Address City State / Province / Region ZIP / Postal Code

CR SUPPORT CHECKBOX

I Need Voucher Funds to Hire a Recreation Support Provider to Assist with Personal Care Issues in a Community-Based, Inclusive Recreation Program:

I am applying for the CARE (Community Access Recreation Engagement) funds for costs of one community-based recreation program, and not PLB, DDR or DDRB funded.

Number of Personal Care Hours:

Personal care hours are ONLY requested if you will HIRE A PERSON to provide toiletting, feeding, and dressing or to address significant behavior needs. Not to exceed 80 hours.

Total Cost of Program: $(Required)

Your Co-Pay (at least 10%): $

Amount of Funds You are Able to Pay in Addition to the Co-Pay: $

Note any funding needs beyond standard voucher

Your Case Manager or Service Coordinator must verify your financial hardship if you cannot pay the required 10% co-pay.

Funding Request: $(Required)

Tell us how much funding you need to attend your program

After School/Extended Day

Indicate How Your Family Will Use Your After School Care Service Hours:

In-Home Care After School

Community Programs After School

Enroll in After-School Program

Check all that apply. NOT AVAILABLE IN ST. CHARLES COUNTY.

Name of After-School Program/School District

Number of After School Care Hours You Are Requesting:

Please Indicate Number of Hours Needed Per Quarter: Unused quarterly hours will be canceled and assigned to other applicants.

1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

NOTE: Parents MUST BE EMPLOYED DURING THE SERVICE. Are the Parents Currently Employed?(Required)

Yes

If yes, email required documentation (employer letter & W2), name, address and phone number of employer(s).

Overnight Camp

I am applying for an overnight camp program of my choice:

Mini Camp

Full Camp Week

Name of Camp Provider:(Required)

Tell us the name of the organization providing your overnight camp program.

Program Name:

Tell us the name of your overnight camp. Examples: Teen Camp; Science Adventures; Arts Week; Tiny Tots Camp

Contact Person:

Camp Dates:(Required)

Camp Provider Telephone Number:

Email Address:

Camp Provider Address:

Street Address City State / Province / Region ZIP / Postal Code

Cost of Program: $(Required)

Camp Deposit (at least 10%): $

Amount of Funds You are Able to Pay in Addition to the Co-Pay: $

Note any funding needs beyond standard voucher

Your Case Manager or Service Coordinator must verify your financial hardship if you cannot pay the required 10% co-pay.

Funding Request: $(Required)

Tell us how much funding you need to attend your program

If applicable complete this portion: Rather than applying for the camp fee, I am applying for support hours for an individual to provide support for the participant at camp.

Number of Hours I Will Need

Use this box ONLY if you are NOT requesting funds to pay for your camp. As funding is available.

The vouchers I have used in the past have helped me

I needed financial assistance

I participated in a meaningful activity

I made my own recreational choices

I am happy with the services provided by the Recreation Council

Check all that apply!

Recreation Council - Universal Voucher Funding Application

All About the Participant

County and Eligibility Info

The Recreation Council Voucher Programs

Experiential Adventure Voucher

Care and Recreation Support Voucher

After School/Extended Day

Overnight Camp

St. Louis County, St. Louis City and Administration Office

St. Charles Office

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