Apply for a Scholarship
Please complete the form below
Date of Birth
Date of Birth
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?
Is your child toilet trained
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?
Does your child have behaviors such as tantrumming, self-injurious, or aggression towards others or themself?
If yes please provide details on behavioral triggers (i.e. task demands, anxiety etc)
Does your child elope?
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)
Pleaser 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 are 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 under 18 in household:
What is Total Family Income?
Does your child receive funding from other sources (state, federal, SSI)? If yes, please describe.
Please provide a summary of out of pocket expenses incurred as a result of participants disability.