Autism Society of McLean County

2011 Takoda Autism Camp
Stipend Application

Requirements:
Stipend 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 stipends. Approved stipend 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


  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. $100.00): $  
Briefly Describe why you want your child to attend Takoda Day Camp:


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