Please complete all information on the application form. You must attach a completed quote or a digital copy of the item that needs to be purchased from the retailer or purchasing source. Additional information may also be sent to support your request. Questions? Please email Adrienne L. Eaglin, SSD Liaison for Special Education Foundation at aleaglin@ssdmo.org. To learn more about our work to support critical needs beyond the classroom, visit the program page. NOTE: You can save your progress on this form and return within 30 days to finish your submission. Just click "Save and Continue Later" to use this feature. Click here for a PDF preview of the form questions.Applicant Name* First Last School Attending* District* Grade* Parent/Legal Guardian Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Phone Number*Parent/Guardian's Consent* The student's parent or legal guardian consents to this request.Information About the Item RequestedYou must include a completed quote or graphic of the item, including the UPC, a detailed specification of the Item, and the supplier.Description*Retailer* Retailer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Retailer Web Address Include "http://" or "https://"Will you provide an image of the item or a link to it?* I will upload an image. I will link to the item. I have both. Image of the Item*Accepted file types: jpg, gif, png, jpeg, heic, Max. file size: 20 MB.Link to the item* Include "http://" or "https://"Stock Numbers Quantity Requested*Price*Statement from Staff That Supports the Need*Statement Describing How This Item Will Assist Student Independence and Well-Being*Statement of Financial Need*This may include information from tax filings. Do not include sensitive information such as an SSN.Staff Name* First Last Staff Phone Number*Staff Email* School* District* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Staff Verification* The staffmember approves the request.Administrator Name* First Last Administrator Verification* The administrator approves the request.
