Online Voucher Request Form - The Arc Pikes Peak Region

The Arc Pikes Peak Region Online Voucher Request Form

Voucher Giving Program:
*arc Thrift Stores provide vouchers to help the community.
*The Arc may request a copy of your photo ID.
*The Arc reserves the right to deny vouchers to any person.

Guidelines:
*A limit of $25 per individual per year (Jan-Dec) to members of The Arc Pikes Peak Region.
*Vouchers must be used by you for the needed items.
*Special requests must be approved by the Executive Director.
*Non-members are required to interview with an advocate to determine need.

Usage:
*One voucher is worth $5.00
*You must spend as close to the $5.00 amount as possible — you will not receive any change or credit for unused portion of voucher(s).
*Vouchers must be used by the expiration date listed at the bottom of the voucher.

The Arc Pikes Peak Region Online Voucher Request Form

DISCLAIMER

Please complete the information below. Vouchers are available to support individuals with intellectual and developmental disabilities. Please do not apply for vouchers if this does not apply to you. LIMIT TO $25 PER INDIVIDUAL

First Name *

Last Name *

Phone *

Date *

Agency Provider *

Amount Requested *

Items Needed: *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Email *

Do you have a disability? *

Please type your full name below, indicating that you have read and do understand that vouchers will only be given to a person with an intellection or developmental disability, and will use the vouchers for the items needed as described above. *

Captcha *

For security verification, please enter any random two digit number. For example: 55

The Arc Pikes Peak Region Online Voucher Request Form

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