Autism Society of McLean County

2011 Takoda Autism Camp
Scholarship Application

Requirements:
Scholarship must be used to enable child to attend the Takoda Autism Camp at Easter Seals Timber Pointe during the week of Camp 2011. You will be notified of approved and/or denied scholarships. Approved scholarships will be paid directly to Easter Seals Timber Pointe upon approval of your child's camp application.

  Contact Information (Parent)

Member ID ASMC-  
     
Name  
Child's Name Age
     
Address or School  

City   State Zip County

Phone
   
Email Address
Confirm Email

  Household Profile

Single Parent Household? Yes     No  
Primary Care Provider Employer/School Name:

Household Size... # Adults:     #Children (under age 18):
   
Names Employer/School Age

  Financial Profile

Total Monthly Gross Household Income (must be completed for processing)
 
Wages / Salary $ Child Support $
Social Security Income $ Unemployment $
Tips/Commission $ Family Support $
Other $    
     
   $
     

The following documentation must be provided by the applicant for processing:

Prior year's Federal Income Tax 1040 Return or past 3 month's pay stubs (for all household  members), or Federal/State Agency Award (i.e. Food stamps, SSI, SSDI)

Include any special circumstances. (Medical bills, illness, unemployment)

Mail or Drop Off Information at:
  ASMC - Autism Camp Scholarship
  2404 E. Empire
  Bloomington, Illinois 61704

  Activity Description

Title:   Takoda Autism Camp at Easter Seals Timber Pointe
Beginning Date: June 13, 2011    Ending Date: June 17, 2011
     
Has this child had this opportunity before? Yes     No  
Projected Cost of Activity:   $200.00  
Funding Amount Requested (max. $200.00): $  
Briefly Describe why you want your child to attend Takoda Day Camp:

  Assessment of Need

Has this child had the opportunities for similar events?  Yes     No
if Yes, by which Group or Organization?
Would this activity be possible without financial support? Yes     No

I certify that the above information is true and complete to the best of my knowledge.