Financial Need Assistance Application

Client's Date of Birth

Parent/Guardian's name

Email Address

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?

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.

If you chose "Other", please explain.

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.

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.

A Capital Campaign for the RECREATION COMPLEX

Financial Need Assistance Application

Els for Autism® Financial Aid Request Form