Scholarship Application

 

 

Walk Contact:  Janine Winn, Controller, j9winn@hotmail.com

                             Erin Pruitt, Director, esrmp2@aol.com

 

Application Date: __________________________________

 

Deadline for submitting this application: April 1st, 2010

 

Please mail your completed application packet to:

Walk for Autism-Charleston

Janine Winn, Controller

P.O. Box 60238

N. Charleston, SC  29419-0238

 

PART I- FAMILY DATA

 

Name of Parents___________________________________________________________________

 

Address ___________________________________________________________________________

 

City _____________________State: ____________County____________Zip Code _________

 

Telephone number: ________________________ Alt. Number _________________________

 

E-mail Address_____________________________________________________________________

 

Annual Family Income:  (optional )___________________________________________

 

Applicant with Autism/ ASD ( PDD-NOS, Asperger’s Syndrome)

 

D.O.B. (required)_________________________        D.O. Diagnosis (required)_________________

 

FULL NAME (required) ___________________________________ INCOME (optional)__________________

                 

** Please fill out a separate application for each child in the family with a diagnosis

 

***Please attach information indicating other additional support funds received for your current program through a non-profit organization, waiver, state agency or insurance company. Include any out of pocket expenses you are required to pay. (Required)

 

 

 

PART II- REFERENCE INFORMATION

Please attach the completed medical report and diagnosis verification form.

 

 

PART III- CURRENT PROGRAM NEEDS

I understand that my child may be eligible to receive a scholarship from Walk for Autism for the purpose of conducting an in-home program for (Applied Behavioral Analysis) or RDI (Relationship Development Intervention) based on completion of this application before the application deadline and for completing the necessary documentation requested.

           

 

*A.     Option I. Applied Behavioral Analysis (ABA)

1. Do you currently have an existing ABA program?  If yes, please briefly describe your program.  If not, what program do you plan on implementing?

 

 

 

 

 

 

 

2. Please read carefully the reimbursement procedures on Form A.  Submit this form with your application.   

 

 

OR

 

*B.    Option II. Relationship Development Intervention (RDI)

1. Do you currently have an existing RDI program?  If yes, please briefly describe your program.  If not, what program do you plan on implementing?

 

 

 

 

 

 

 

 

2. Please read carefully the reimbursement procedures on Form B. Submit this formwith your application.

 

 

 *C.      Option III.  Alternative Therapies Not Covered By Insurance

1. The Walk for Autism will allow scholarship recipients to use up to 20% of their total scholarship on therapies not covered by insurance. Includes therapeutic horseback riding, music therapy, vision therapy, therapeutic listening etc.

 

2. Please read carefully the reimbursement procedures on Form C.  Submit this form with your application.

           

 

 

*Information provided to the Walk for Autism does not affect scholarship allocation.  Information is gathered in the event of an IRS audit.

 

 

 

 

 

PART IV 

 

TERMS AND CONDITIONS

 

 

l       I understand that my child is eligible to receive funding only for the purpose of conducting an in-home ABA or RDI program.  Approximately 20% of your application can be used toward other one-to-one therapies that are not covered by insurance.

 

l       I understand that the Walk for Autism Scholarship Fund has been established primarily for the purpose of the intervention and treatment of autism.

 

l       I understand that all monies will be dispersed equally amongst all qualified recipients within 60 days of the walk event and in accordance with the federal tax laws governing 501 (c) (3) agencies.

 

l       I understand that Walk for Autism provides scholarships for a period of one year.

 

l       I understand that any unused portions of my scholarship, as specified by this application, will return to Walk for Autism.

 

l       I understand that if at any time I discontinue my ABA or RDI program, I am required to notify Walk for Autism in writing and my scholarship will return to the organization.

 

A.     I understand that I am responsible for verification and documentation of costs incurred in conducting my in-home ABA or RDI program and that I am required to submit forms specified by this application in a timely manner and in due process.

 

B.     I understand that I am responsible for filing 1099 forms as stated by the IRS for therapists and consultants who work specifically as independent contractors.

 

l       I understand that any and all information pertaining to my application and scholarship is confidential.

 

 

I have read the preceding information. I understand and agree to the terms and conditions stated above.

 

Signature of parent or legal guardian                                            Date