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Financial Aid Request Form

Els for Autism® Financial Aid Request Form

Participants Name(Required)

Does the child have a diagnosis of autism spectrum disorder (ASD)?

If the child does not have a diagnosis, is the child currently on a waiting list to receive a diagnostic evaluation?

Does the child demonstrate behavioral challenges?

Does the child have a sibling or other family member living in the home with ASD?

Has the child received scholarship funding from the Foundation in the past?

List type of therapy received:

As the parent/guardian, do you agree to provide a 1:1 companion/support assistant during any group programming at Els for Autism requiring independent participation in a 1:3 (1 staff to 3 clients) ratio?

Please select the program(s) that you are interested in:

Terms and Conditions of Els for Autism Financial Aid Requests

Through the generous donations of local and national supporters, Els for Autism is pleased to provide financial aid opportunities to families of clients with autism spectrum disorder for select programs and services.

1. Financial aid is available for Els for Autism families and clients demonstrating financial need.

2. Partial or full financial aid may be awarded.

3. All financial aid requests will be handled in a confidential manner.

4. To be eligible, a client MUST have a confirmed diagnosis of autism spectrum disorder.

5. Award is limited to one financial aid, per client with autism, per program. A second child with autism in the samefamily may be eligible for a separate financial aid award. For example, a family may be awarded 50% financial aid for one 4-week session of group music therapy and a 50% scholarship for group golf lessons.

6. Els for Autism reserves the right to verify all information contained on the financial aid request form and to request additional information.

7. Applicant must state annual household gross income on financial aid request form. Income reported may besubject to verification by W-2, payroll stub, or federal income tax returns.

8. Certain actions by Applicant may result in loss of a financial aid ward, including but not limited to, excessive tardiness, unapproved cancellation or unexcused absence from scheduled sessions, lack of cooperation, behavior that is deemed inappropriate, continually disruptive, hazardous, or unsafe.

9. To apply for financial aid, please complete the Financial Aid Request Form.