Request Resources – Telic Empowerment

Telic provides educational, financial, independent living, and health resources to benefit families that have a special needs child or young adult. If you are in need of assistance please fill out the form below.

Resource Request Form

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Name^*

Requestor's name

Email^*

Phone Number^*

In which county do you currently reside?^*

Age of Disabled Child/Adult^*

please select one

Type of Disability^*

Type of Resource Requested^*

Medical
Financial
Educational
Independent Living

Description of what you are looking for. Be specific^*

example: school not adhering to IEP, childcare for child with autism and aggressive behavior

What is your annual family income?

*Needed to qualify for certain grants

Person Requesting Resources is^*

I have read and agree to Telic's Terms and Agreements^*

Both checkboxes required

Resource Request Form

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