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Hanover Arc Services On-Line Request Form

Hanover Arc, Inc.
P.O. Box 91 Ashland, VA 23005
Tel: (804) 798-2400
Fax: 798-0310
Email Hanoverarc@aol.com

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APPLICATION FOR SERVICES
*Required Field

*First Name

*Last Name
*Sex
*Ethnic Status

*Address

*City

*State

*Zip

*County of Residence

*Home Phone

Work Phone

*Birth Date

Email

Parent/ Caregiver

Telephone

Address

City

State

Zip

Applicant Employer

Telephone

Mother's Employer

Telephone

Father's Employer

Telephone

Legal Guardian

Telephone

Check Service Section That You Are Requesting
     

Adaptive Equipment

Item Requested

Item Cost

Financial Aid Requested
   

Respite & Recreation

What is the respite/ recreation activity and when will it occur?

Cost

Financial Aid Requested
   

Summer Education Scholarships

What is the educational program (name, location, dates)?

Cost

Financial Aid Requested

Current School

Teacher
   

Adult Recreational Services

Check Any of the following resources that the applicant is receiving (below).

Temporary Assistance For Needy Families   

SSI

SSDI and or SSA              

Hanover Comm. Services Board Services

MR Medicaid Waiver or Other Waiver

What is the family’s (or adult’s if over 18) total gross income per month?  (Gross income includes all gross salaries, child support, alimony, welfare, pension, SSI, all other income sources)

Number of dependents.

List present outstanding and/or unusual (not luxury items) expenses owed.

Do you wish to join the Hanover Arc?

Yes, Will Send $15 dues
No

 

 

 


 

PHOTO/VIDEO AUTHORIZATION -  I give OR  I do not give permission to the Hanover Arc to use photos or videotapes of the applicant for public education, publicity, fund raising or other events.

You will be mailed a release form to sign an date, to make this release official.

 
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