Funding Form | STAR NET Region I and III

Funding – Family/Professional Fellowship Application

Please read the overview page carefully before registering.

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Personal Information

You MUST provide your HOME address (NOT school/agency). The fellowship contract would be with you as an individual and, therefore, the reimbursement check must be mailed to your home address.

First Name*

First Name

Last Name*

Email*

HOME Address*

City:*

Zip Code:*

Primary Phone:*

Secondary Phone:

Event Information

Event Information*

Date (Event Must Be At Least 1 Month Away)*

Event Location*

Sponsor*

How event applies to the child in your family or the children served (supporting documentation encouraged)*

Type of Fellowship

Type of Fellowhip*

Select One Below

Select One Below
Family
Professional

If you are applying as a family member, do you have a child two through six years of age receiving Early Intervention services or Early Childhood Special Education Services in Illinois?*

Yes

Not applying as a family member

If you are applying as a professional, do you serve children ages 3-5 with IEPs?*

Yes

Not applying as a family member

District/Agency

Address (of district/agency)

City

Zip Code

Principal/Supervisor

Phone

Amount Requested - itemize projected expenses up to $150 (up to $350 for SAV Conference)

Registration:

Mileage ($.76 / Mile Round Trip):

Lodging:

Child Care:

Substitute (max. $100):

Total (min. $25):*

Other sources for financial assistance:

Have you Previously received a fellowship?*

Yes

Date

* indicates a required field - You won't be allowed to submit until these fields are entered