Watch Me Thrive ScholarshipWatch Me Thrive scholarships are made possible by donations and annual Summit Future Foundation events.Scholarships for other programs may be available upon individual basis. Donate Now Parent/Guardian Name * First Name Last Name Parent/Guardian Phone * (###) ### #### Email * Participant's Name * First Name Last Name Participant's Date of Birth * MM DD YYYY Grade in School * Does participant have a developmental disability diagnosis? Does participant have any medical diagnosis? Does your child have any medical activity restrictions? If yes, please describe. How does your child communicate? Verbal Gestures Device Is your child toilet trained Yes No If no, please provide details on child’s current level of dependence with toileting. Does your child need physical assistance with mobility (standing, walking etc)? Does your child need physical assistance to feed self? Yes No Does your child have behaviors? Such as trantrumming, self-injurious, or aggression towards others or themselves? Yes No If yes, please provide details on behavioral triggers (i.e. task demands, anxiety, etc). Does your child elope? Yes No Safety concerns? Yes No If yes, please provide additional details. What level of support does your child receive at school? (adult:child ratio) 1:1 1:2 1:4 Please provide details (support for safety, communication, elopement, etc) Please provide any other details of how your child's disability affects them, if not listed above. What helps your child be successful? How does your child learn best? (visual, auditory, multi-sensory etc) What are your child's preferred activities? What are your child's talents or things they're good at? Does your child have any strong dislikes? Please provide any other information about your child that you feel is important. Please describe what positive impact a scholarship would have for your child. Number of adults in household Number of children in the household, under the age of 18 What is total family income? Does your child receive funding from other sources (state, federal, SSI)? If yes, please provide. Please provide a summary of out of pocket expenses incurred as a result of participants disability. Thank you!
