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Capital Campaign

Support Our Capital Campaign
to Build a Specialized Autism Friendly
Recreation Complex

Donate now to make a splash!

A Capital Campaign for the RECREATION COMPLEX

Expanding recreation activities available at The Els Center of Excellence® campus.

Recreation Complex

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Financial Need Assistance Application

Els for Autism® Financial Aid Request Form

Client's Name(Required)

First Last

Client's Date of Birth

Parent/Guardian's name

Email Address

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

YES

NO

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

YES

NO

Does the client demonstrate behavioral challenges?

YES

NO

If yes, please provide details.

What is the total gross income of all members of the family household? $

How many individuals live in the family’s home?

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

YES

NO

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

YES

NO

If yes, please provide details.

Does the client currently receive any therapies? If yes, please provide the number of hours of therapy the child receives each week.

List type of therapy received:

ABA Therapy

Speech-Language Therapy

Occupational Therapy

Music Therapy

Mental Health Counseling

Other

If you chose "Other", please explain.

As the parent/guardian/client, do you agree to provide a 1:1 companion/support assistant during any group programming at Els for Autism requiring independent participation as needed?

YES

NO

Does the client have insurance that includes coverage for therapeutic interventions (e.g., Applied Behavior Analysis- ABA Therapy), Speech-Language Therapy, etc.)? If yes, please list the name of the insurance company.

In the space provided below please write a small statement declaring why you need this Financial Aid Assistance.

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

Spring Break Camp

Summer Camp

Recreation Programs (e.g., Sports, Fitness, Reach & Teach through the arts)

RUBI Parent Training

SIA Together

Other

What level of financial assistance are you requesting? (Please indicate a percentage such as 5%, 10%, 20%, 25% etc.)

By submission of this form, I acknowledge I am current client of Els for Autism Foundation ® and I have read, agree to, and accept the Terms and conditions provided to me.

The Els for Autism global mission is to transform the lives of people with autism and those who care for them through lifetime services and collaborative partnerships.
Where possibilities are endless.

Els for Autism is a US public charity (EIN #26-3520396)

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Copyright 2024 Els for Autism Foundation. The Els Center of Excellence, Ernie Els #GameON Autism, Els for Autism, Els for Autism Foundation, Ernie Els Els for Autism + Flag device and the Ribbon logo are trademarks of Blue Ocean Trademarks NV. The contents of this website are copyright works. All Rights Reserved.

CONTACT ELS FOR AUTISM

General Inquiries
561-598-6200
info@elsforautism.org

Copyright 2024 Els for Autism Foundation. The Els Center of Excellence, Ernie Els #GameON Autism, Els for Autism, Els for Autism Foundation, Ernie Els Els for Autism + Flag device and the Ribbon logo are trademarks of Blue Ocean Trademarks NV. The contents of this website are copyright works. All Rights Reserved.

CONTACT ELS FOR AUTISM

General Inquiries
561-598-6200
info@elsforautism.org

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