Andersen Scholarship Application Applicant Name(Required) First Last Home Address(Required) Street Address City ZIP / Postal Code Home Phone(Required)Cell/Other Phone(Required)Email Address(Required) Child(ren) Information: Please list all children who you would like to receive funding.Child Name(Required)Age(Required)Diagnosis(Required)Child NameAgeDiagnosisChild NameAgeDiagnosisChild NameAgeDiagnosisPlease list all children in your home who DO NOT require funding.Child Name(Required)Age(Required)Diagnosis(Required)Child NameAgeDiagnosisChild NameAgeDiagnosisChild NameAgeDiagnosisFunding SourcesPlease list any funding you have received in the past 12 months or expect to receive in the next 12 months, including TRE, insurance, and Medicaid. please include CNA hoursFunding(Required)Funding SourceAmount received in the past 12 monthsAmount expected in the next 12 monthsChild(ren) receiving funding Add RemoveCurrent ServicesSchool District(Required)Do you expect to receive ESY Services for the coming summer?(Required) Yes No Is this child involved in social skills training through the school?(Required) Yes No Please describe what kind of social skills training.What services are currently being provided outside of school? Please include respite care.ServiceProviderHours per weekChilds nameServiceProviderHours per weekChilds nameServiceProviderHours per weekChilds nameServiceProviderHours per weekChilds namePlaydate FundingHave you ever received assistance from this scholarship fund?(Required) Yes No Month/YearAmountServiceChildMonth/YearAmountServiceChildMonth/YearAmountServiceChildTypes of Services requested (Please check all that you would like.) ABA Therapy Respite Educational Placement Parent Training/Workshops Other If you chose other, please explain.Reasons for choosing these services. (please explain)Amount you are able to contribute weekly?(Required)Please check each box indicating you understand the following( Must select all)(Required) I understand that I will not receive funds directly. I understand that my child/children must maintain consistent attendance. I understand that every family must pay a monthly co-pay. I understand that I must apply for outside funding each calendar year. I understand that all of the above are conditions for retaining this scholarship. I understand that there is no guarantee of renewal of scholarship(s). SignatureDate MM slash DD slash YYYY
