Takoda Camp Scholarship application

This application is available to AM members in good standing (current membership) and must be used for Takoda Camp hosted by Autism McLean. Applications are reviewed and approved/denied by the AM Board of Directors. You will be notified whether the application is approved or denied. An approved application will be deducted from the Autism McLean activity fee upon approval of your child’s application.

Contact information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Who is this stipend for? *

First

Last

What is their age?

Household profile

Single parent household?

Primary care provider employer or school name

Number of adults in the household *

Number of children (under 18) in the household *

Financial profile

Total monthly gross household income (must be completed for processing). The following documentation must be provided by the applicant for processing: prior year's Federal Income Tax 1040 return or past 3 month's pay stubs (for all household members), or federal/state agency award (i.e. food stamps, SSI, SSDI). Include any special circumstances (medical bills, illness, unemployment).

Wages / salary

Tips / commission

Social security income

Child support

Unemployment

Family support

Other

Camp information

Date of camp

Has this child had this opportunity before? *

Your projected cost for camp *

Funding requested *

Describe why you want your child to attend camp *

Assessment of need

Has this child had opportunities for similar events? *

If yes, by which group or organization?

Would this activity be possible without financial support? *

Comment