SVAP Scholarship Form

SVAP Scholarship Application
Because of the generous community support and our annual “Valley 5K Walk/Run for Autism” fundraiser, SVAP offers monetary scholarships on a limited basis for individuals on the Autism Spectrum, as well as those who support and care for persons on the spectrum. These funds may be used towards services such as respite, therapies, safety, sensory equipment, and personal/professional development.

Scholarships are limited to persons residing in the following Virginia counties/cities in the Shenandoah Valley: Counties of Augusta, Bath, Frederick, Highland, Page, Rockbridge, Rockingham, Shenandoah, Warren, and the Cities of Buena Vista, Harrisonburg, Lexington, Staunton, and Waynesboro.

Possibilities for scholarships include, but are not limited to, the following:

• Swimming lessons
• Music lessons
• Respite care
• Sensory equipment
• Conferences (for parents, professionals and/or individuals on the spectrum)
• Assistive technology
• Occupational, physical, or speech therapy
• Behavioral therapy consultations
• Mentors or tutors
• Social skills training

Scholarship requests are limited to a maximum of $500 per year. This allows us to help as many individuals as possible. As each scholarship is granted based on the need, occasionally requests for more than $500 will be considered. Preference will be given to those who have not previously been given a scholarship.

Professionals or guardians may assist older children or adults on the autism spectrum with the application process.

The scholarship committee will review the completed applications. The committee may try to find alternate ways to help the individuals who apply. For example, if the scholarship request is for swimming lessons, the committee may suggest a facility that would offer this service at no charge. If a scholarship is approved, in most cases the service provider or vendor will be paid directly.

Please share the attached application with anyone who may be interested. If you have questions, contact us. If you want to get involved, please join us.

Shenandoah Valley Autism Partnership
www.valleyautism.com
ValleyAutismInfo@gmail.com
Have you previously applied for an SVAP scholarship?

Yes No

If yes, provide us with the following information:
If yes, provide us with the following information: Date , Amount $ , and Service/Activity/Product .

Request for Individual:

Please complete this section for the person who will be receiving the scholarship. For professionals applying for a scholarship for a school or community organization, please type NA and continue to the next section.
Individual's Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Diagnosis (scholarship applicants must be on the Autism Spectrum). Please note that SVAP may ask for a letter of recommendation confirming diagnosis: *

Please upload a letter of recommendation and/or other documentation that supports this scholarship: *

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IMPORTANT: No scholarships will be processed until a letter of recommendation and/or other documentation supporting this scholarship
Cancel of

Guardian/Therapist Contact Information:

If applicable, please provide the information on the legal guardian and/or therapist of the individual receiving the scholarship. For professionals applying for a scholarship for a school or community organization, please type NA and continue to the next section, "Organization Contact Information."
Legal Guardian's Name: *

First Name Last Name
Legal Guardian's Full Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Legal Guardian's Telephone Number: *
Please enter a valid phone number.
Legal Guardian's Email: *
example@example.com

OPTIONAL: If you are a therapist/provider filling out this application on behalf of your patient, please answer the following
Therapist/Provider Name:

First Name Last Name
Therapist/Provider Email Address:
example@example.com
What is the best way/time to contact you?

Email Phone Morning Evening

Organization Contact Information:

If you just filled out the previous section, please skip this section and go on to Contact Information. If you are an organization, please complete this section in its entirety.
Organization or School's Name:
(Example: Mountain View Elementary School)
Your Name and Affiliation with the Organization:
(Example: Special Education Teacher)
Your Phone Number:
Please enter a valid phone number.
Your Email:
example@example.com

Specific Description of Funding Request:

Please include as much information as possible in the sections below. Incomplete applications will not be considered.
Specific Monetary Amount Requested ($): *
Description of Service, Activity or Product: *
(What do you want, how will it help, etc.)
Please provide the links for products. Amazon links preferred, if possible. *
If requesting funding for a service (e.g. speech lessons) or activity (e.g. riding lessons), what is the duration?
Name and Contact Information of Service Provider/Camp (if applicable)

Name Contact Information
How will SVAP pay for the request (payment by check, pay online). *
Note: It is our policy to not award money directly to our applicants
Do you have any documentation justifying the request? *
No scholarships will be processed until a letter of recommendation and/or other documentation (e.g. email from service provider) supporting this scholarship is sent to ValleyAutismInfo@gmail.com Be sure to include your name and who the request is for in the email.
Please name other agencies or services also contacted for funding. Please indicate which have been contacted and total amount requested or received (if any): *
If none, type none

Electronic Signature:

By signing below, I affirm that all of the information provided on the previous pages is true and complete as of this date.
Full Name: *

First Name Last Name
Today's Date: *

Month Day Year
I affirm that all of the information provided on the previous pages is true and complete as of this date. Please sign below: *

Clear

SVAP Membership Interest

ALL SCHOLARSHIPS COME WITH A ONE-YEAR MEMBERSHIP TO SVAP. Be sure to like the Shenandoah Valley Autism Partnership page on Facebook, or visit http://ValleyAutism.org for more information.
I am interested in helping the Shenandoah Valley Autism Partnership. Please contact me.

Yes No
Your Name:

First Name Last Name
Your Email:
example@example.com

Should be Empty:

SVAP Scholarship Application

Request for Individual:

Guardian/Therapist Contact Information:

Organization Contact Information:

Specific Description of Funding Request:

Electronic Signature:

SVAP Membership Interest