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Special Interest Scholarship Application
The KNOWAutism Foundation Special Interest Fund was established to help children with autism access adaptive and inclusive programs and services that do not fall under the umbrella of traditional autism treatments or interventions. If you are seeking financial assistance for traditional therapeutic intervention services such as speech therapy, occupational therapy, ABA therapy, specialized private schools or education, please complete the Tuition and Therapy Application. Please Note: This fund does not cover experimental procedures, day care, after school care HBOT, supplements, acupuncture, homeopathy, or other alternative treatments. Applicants will be notified before March 31, 2024, via email if they have been selected to receive a scholarship.
Eligibility Requirements
Applicants must reside in the Greater Houston Area (in one of the following counties: Austin, Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery and Waller), demonstrate a need for financial assistance and provide relevant information for the committee to review. Applications must be completed by the parent or legal guardian of the dependent. There is not an age requirement as long as the individual has a formal autism spectrum disorder diagnosis. If the individual is over the age of 18, you must provide legal documentation of guardianship for the dependent. Eligible programs/services include (but are not limited to): special needs camps or summer programs, music therapy, art therapy, inclusive fine arts programming, adaptive sports or therapeutic movement programs such as yoga therapy, adaptive dance, and adaptive swim lessons, therapeutic horseback riding (equine therapy), services for a special needs advocate or attorney (up to $1,000). Only one (1) service/program may be requested per application per recipient/dependent. Scholarships are only awarded once per calendar year to each selected recipient. This application is NOT for speech therapy, occupational therapy, physical therapy, or Applied Behavior Analysis (ABA) therapy. Submissions for those therapies on this application will not be considered. Instead, you should complete the Tuition and Therapy Application. If you are seeking assistance for more than one dependent, a separate application must be submitted for each individual. Parent/Guardians must provide documentation of an ASD diagnosis. This may be in the form of a diagnostic assessment or report, copy of IEP, SSI or Medicaid determination letter, documentation from school district, or other similar documents. Review Process: The Program Committee reviews applications 3-4 times a year and selects a limited number of applicants to receive financial support scholarships. A member of the committee may contact you to request additional information or documentation, if needed. Applicant information remains confidential during the review process. Once a decision has been made regarding your application, a committee member will contact you at the e-mail address provided on your application. Award Acceptance Requirements: If you are selected to receive a scholarship, you will receive an award letter and an acceptance agreement, which must be read, signed, and returned, via email. You will also need to provide a detailed invoice for services/program, a thank you note, a photo of the scholarship recipient, a :30 video of the scholarship recipient, and grant permission for the KNOWAutism Foundation to use the scholarship recipient's first name, photographic likeness, and video likeness in its publications, social media, website, fundraising materials, and/or other media before any payments are distributed. Incomplete applications will not be considered. Please note: all payments will be made directly to the service provider or school on behalf of the scholarship recipient. Only one (1) service/program may be requested per application, per individual, per year.
Do you reside in the Greater Houston Area? Defined as residing in one of the following 9 counties: Austin, Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery and Waller.
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Please Select
Yes
No
Is the scholarship applicant a U.S. Citizen? Please note: we are only accepting applications from U.S. Citizens at this time.
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Please Select
Yes
No
Date of Application:
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Month
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Day
Year
Date
Scholarship Applicant's Full Name:
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First Name
Last Name
Scholarship Applicant's Date of Birth:
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Year
Scholarship Applicant's Gender/Sex:
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Please Select
Male
Female
Date of Autism Spectrum Disorder Diagnosis (Diagnostic assessment required with this application):
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Month
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Day
Year
Diagnosis/es:
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Is the scholarship applicant verbal or non verbal?
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Describe how the scholarship applicant's Autism Spectrum Disorder manifests itself (meaning what behaviors, traits, symptoms your child exhibits). The more information, the better.
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Has the scholarship applicant received any therapeutic services prior to today including speech therapy, occupational therapy or ABA therapy? If yes, please list each type of therapy, how long the scholarship applicant received services for, the name of the provider, and any notes about each therapy/intervention. Please indicate if the services have been offered by the school district or a therapy clinic. The more information, the better. If no, enter N/A.
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Parent/Guardian #1's Name (person completing this application):
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First Name
Last Name
Parent/Guardian #1 Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian #1 email:
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example@example.com
Parent/Guardian #1 Cell Phone Number:
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Please enter a valid phone number.
Parent/Guardian #1's marital status:
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Please Select
Married to parent/guardian #2
Living Separately, but legally married to parent/guardian #2
Domestic Partnership
Married to someone other than parent/guardian #2
Divorced
Widowed
Never married
Parent/Guardian #2's Name:
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First Name
Last Name
Parent/Guardian #2's marital status:
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Please Select
Married to parent/guardian #1
Living separately, but legally married to parent/guardian #1
Domestic Partnership
Married to someone other than parent/guardian #1
Divorced
Widowed
Never married
I do not know
Other
Parent/Guardian #2 Address (if different from Parent/Guardian #1):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian #2 email:
example@example.com
Parent/Guardian #2 Phone Number:
Please enter a valid phone number.
Name of the provider or facility you are requesting services from (and that we will pay directly, if awarded a scholarship)?
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Provider/Facility Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility Phone Number:
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Please enter a valid phone number.
Facility/Provider Contact Name:
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Facility/Provider Contact email:
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example@example.com
Has the scholarship applicant received services from this provider before?
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Please describe the program/service you are requesting financial assistance to cover and how it will be helpful for the scholarship applicant.
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Total cost of program/services being requested and designate the time frame for the services (per week, per visit, per month, etc.) For example, I want my son Jack to receive swim lessons for two months. It costs $200 a month for 4 swim lessons. The amount you would enter below would be $400 = $200/month x 2 months.
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How often would you like for the scholarship applicant to receive services or for how long?
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Grant amount requesting:
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Gross Annual Income for parent/guardian 1 (Household):
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Parent/Guardian 1's number of dependents (defined as a person (usually a child) you claim on your tax return as a legal dependent under the age of 19, unless attending college and then the child can be up to the age of 26. Please include any legal dependents you have guardianship for). DO NOT INCLUDE yourself or spouse. A copy of parent 1's tax return is required with this application):
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Do any of parent/guardian 1's other legal dependents have special needs? If so, please list their name(s), age(s), and diagnoses.
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Gross Annual Income for parent/guardian 2 (Household):
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Parent/Guardian 2's number of dependents (defined as a person (usually a child) claimed on their tax return as a legal dependent under the age of 19, unless attending college and then the child can be up to the age of 26. Please include any legal dependents you have guardianship for). DO NOT INCLUDE yourself or spouse. A copy of parent 2's tax return is required with this application unless they do not have legal custody of the scholarship applicant. If parent/guardian #1 and parent/guardian #2 are married, please enter N/A.
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Do any of parent/guardian 2's other legal dependents have special needs? If so, please list their name(s), age(s), and diagnoses. If parent/guardian #1 and parent/guardian #2 are married, please enter N/A.
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If parents/guardians of the scholarship applicant are not legally married, who has court ordered decision making authority for educational, medical and psychiatric treatment for the scholarship applicant? If parent/guardian #1 and parent/guardian #2 are legally married to one and other, type N/A
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If the parents/guardians are not legally married, does the other parent/guardian provide any type of financial assistance for the scholarship applicant? If the other parent/guardian is court ordered to provide child support and/or cover out of pocket medical expenses but does not currently pay, please include relevant information. If not applicable, please type N/A.
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Does parent/guardian #1 currently receive SSI for themselves?
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Please Select
Yes
No
Does parent/guardian #2 currently receive SSI for themselves?
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Please Select
Yes
No
I do not know
Does the scholarship applicant you are applying on behalf of currently receive SSI?
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Please Select
Yes
No
Has the scholarship applicant you are applying on behalf of received SSI in the past? If they have received SSI in the past but are not currently receiving this benefit, please explain. If the dependent has been approved for SSI but has not yet received payments, please include that information. If not applicable, please enter N/A.
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Is parent/guardian 1 legally disabled and receiving disability benefits?
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Yes, I am legally disabled and am receiving disability benefits.
No, I am not legally disabled.
Yes, I am legally disabled, but I am not receiving any benefits.
Yes, I am legally disabled and have received disability benefits in the past, but am not currently.
Is parent/guardian 2 legally disabled and receiving disability benefits?
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Yes, parent 2 is legally disabled and is receiving disability benefits.
No, parent 2 is not legally disabled.
Yes, parent 2 is legally disabled, but is not receiving any benefits.
Yes, parent 2 is legally disabled, has received disability benefits in the past, but is not currently receiving any disability benefits.
I do not know if parent 2 is receiving disability benefits.
What other types of financial assistance does parent/guardian 1 receive? Please include all financial assistance from the government, family, friends, place of worship, significant others, etc. (Please note: Receiving assistance from additional sources does not necessarily go against the scholarship applicant. The grants committee is looking for a wholistic view of your financial situation. We applaud parents/guardians who are resourceful and are doing everything they can to provide for the scholarship applicant.):
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What is parent/guardian #1's current living situation?
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Own Home
Rent Home/Apartment/Residence
Live with family
Live with boyfriend/girlfriend or other person you are not legally married to (does not include family)
Live in government subsidized housing
Other
If other, please explain.
Monthly rent/mortgage
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Is the scholarship applicant currently covered by private medical insurance (not including Medicaid)?
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Please Select
Yes
No
If yes, what type of medical insurance plan is the scholarship applicant covered under (not including Medicaid)? This type of insurance is usually provided by a parent's employer or the Healthcare Marketplace/Obamacare.
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Please Select
PPO through parent/guardian's employer
HMO through parent/guardian's employer
HMO through Marketplace
Other
None
Name of insurance company (not including Medicaid; a copy of the front and back of the insurance card is required with this application):
Primary insured's Name:
Deductible:
In network out of pocket max:
Out of network out of pocket max:
Is the scholarship applicant currently enrolled with Medicaid in Texas?
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Please Select
Yes
No
If yes, what plan is the scholarship applicant currently enrolled in?
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Please Select
Texas STAR (typically low income)
STAR Kids (Children and adults 20 years and younger who have disabilities)
STAR + PLUS (Adults with disabilities or are 65 or older)
STAR Health
Traditional Medicaid (available only if not enrolled STAR, STAR+PLUS, STAR Kids, or STAR Health)\
Not enrolled in Medicaid
Are any of the services you are requesting financial assistance with covered by medical insurance (not Medicaid)?
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Please Select
Yes
No
If yes, is the provider you are seeking assistance with in network?
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If these services are covered by medical insurance (not Medicaid), what is your expected out of pocket for the services you are requesting assistance for? If not applicable, please enter N/A.
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Describe your particular financial situation and why you are seeking financial assistance. Detailed responses are encouraged.
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Have you applied for financial aid, scholarships, grants, or other type of financial assistance from any other organizations or agencies to cover any part of the requested services?
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Please Select
Yes
No
If yes, please include the names of the entities from which you have applied, the date, and the amount of assistance requested. If not applicable, please enter N/A.
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If you have been awarded financial assistance from another entity to cover any part of this request, please list the name(s), amount(s), and time period(s). If not applicable, please enter N/A.
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Has the dependent previously received a grant from the KNOWAutism Foundation?
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Please Select
Yes
No
If yes, list year(s) and amount(s) awarded:
How did you hear about our grants program? Please be specific
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By signing this form, you certify that all answers provided are true and complete to the best of your knowledge. I understand that incomplete applications will not be considered. I understand knowingly providing false information will disqualify my family from consideration for all current and future grants offered by the KNOWAutism Foundation. I grant permission for the KNOWAutism Foundation to contact individuals and entities listed on this application for verification and to collect additional information, if needed. I understand a maximum of one application per scholarship applicant may be submitted every twelve (12) months from the date of the last application. I understand I may withdraw my application, at any time, in writing to info@know-autism.org.
Full Name
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Signature
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Today's Date
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Month
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Day
Year
Diagnostic Assessment
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Detailed Invoice from Provider for services requested for the scholarship applicant:
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Parent/Guardian #1's 2022 Tax Return (social security numbers may be redacted):
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Parent/Guardian #2's 2022 Tax Return (social security numbers may be redacted):
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Medical Insurance Card for scholarship applicant (front):
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Medical Insurance Card for scholarship applicant (back):
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Medicaid Card for scholarship applicant (front):
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Certified Divorce Decree/Custodial Agreement:
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Current IEP Plan
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Progress Report
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Other (anything additional you'd like considered):
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