2019 Camp Scholarship Application
PERSONAL INFORMATION
County of Residence *
Name of Child *
Your answer
Date of Birth *
MM
/
DD
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YYYY
Parent/Guardian Name *
Your answer
Your Mailing Address *
Your answer
Phone Number (no dashes) *
Your answer
Email Address *
Your answer
CAMP INFORMATION
Scholarships will be awarded for any summer camp or summer program, not just autism-specific camps. For example, the Scholarship could be applied toward "Kids' and Teen College" at the College of Southern Maryland. Scholarship award will be up to, but shall not exceed, $150.00.
Name of Camp or Program *
Your answer
Camp Section or ID Number (if applicable or known)
Your answer
Date(s) of Camp *
Your answer
Total Cost of Camp *
Your answer
Child is Already Registered at This Camp *
Name of Camp Point of Contact *
Your answer
Phone Number of Camp Contact (no dashes) *
Your answer
Camp Email Address or Camp Contact Email Address (if known)
Your answer
Camp Payment Address *
Your answer
PROOF OF AUTISM DIAGNOSIS
All applicants must provide proof of a diagnosis of an autism spectrum disorder (ASD). This proof of diagnosis should be a copy of the front page of your child's IEP, or the diagnosis letter from a doctor or medical professional on official letterhead, or a similar proof. If you have any question on what to use, please contact us. This information shall be kept confidential and is not released to the camp, nor is it released to the public or to any school or agency.
I will email proof of my child's disability to info@autismsupport-somd.org *
I will mail proof of my child's disability to the Autism Spectrum Support Group of SOMD, PO Box 2162, California MD 20619 *
NOTE: APPLICATIONS WILL NOT BE CONSIDERED UNTIL PROOF OF DISABILITY IS RECEIVED.
POLICY:
Application information and proof of an autism spectrum disorder diagnosis must be provided for the application to be processed.

There are a limited number of camp scholarships, up to $150.00 each, available for individuals with autism in Calvert, Charles, and St. Mary's Counties. Scholarships will be awarded on a first come, first served basis (by postmark or email or online timestamp).

Families are now eligible to apply for a camp scholarship every three (3) years. Families who have received a camp scholarship at any time since January 1, 2017 will not be eligible for a scholarship award in 2019.

Application materials (including diagnosis) and selection of a camp must be received no later than 11:59 PM on May 25, 2019.

Recipients of scholarship awards will be notified by phone or email no later than June 1, 2019.

Scholarship monies will be paid directly to the camp or program designated above once proof of registration is verified. We do not provide reimbursement to parents. If you have already paid for camp, it is your responsibility to verify with the camp that monies you have paid would be refunded to you. Monies are not paid or refunded to you if your child fails to attend the camp.

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This form was created inside of Autism Spectrum Support Group of Southern Maryland.