Beyond Words Foundation for Autism - Summer 2019 Provider Application
Please complete this application in its entirety. Before a student's application can be officially accepted and and considered for a scholarship, we need to receive this form before April 15, 2019.

Reminders:
(1) We do not provide 100% scholarships. We value the family's monetary commitment to the service. Applications requesting the minimum needed scholarship amount being 100% of the total tuition, will automatically be denied.
(2) We consider scholarships to services that are recreational in nature, not services that are academic or included on the student's IEP. Please consult the website for an idea of services that are and are not considered.
(3) Scholarship award letters will be mailed May 15th.
(4) It is not guaranteed that a complete application will receive a scholarship. Incomplete applications will automatically denied.
(5) Scholarship money will be distributed only after the service has been provided. Therefore if you, as the service/organization, require payment before the service is provided, it is the parent/caregiver's responsibility to work out these registration details. Our scholarships will be applied to services that are provided between June 1-August 31, 2019 ONLY. The awarded scholarship can only be used for the service applied for and is non-transferrable to another service without approval from the Board of Directors (requiring prior written notice).

Person Completing This Form *
Your answer
Relationship to Provider/Agency *
Your answer
Student Name *
Your answer
Diagnosis *
Your answer
Parent/Guardian Name *
Your answer
Company/Organization Providing Service *
Your answer
Organization/Provider Name *
Your answer
Provider Address *
Street, City, State, Zip
Your answer
Therapist or Instructor's Name *
Your answer
Billing or Administrative Contact's Name
if different from the above
Your answer
Billing Phone Number *
Your answer
Billing Email *
Your answer
Type of Service Requesting Scholarship For *
(i.e. swimming, horseback riding, music, etc.)
Your answer
Dates of Service Requesting Funding For? *
June 1 - August 31, 2018 only
Your answer
Total Amount of the Service *
June 1 - August 31, 2018 only
Your answer
Has the student ever received these services before? *
If so, how long?
Your answer
Student's Attendance with Prior Services
Your answer
Do you have a deadline for registration *
If so, when?
Your answer
Do you charge for services not provided? *
(i.e. absences, late registration, cancellations, etc.)
Your answer
Is payment for services required before services are provided? *
Your answer
If so, is your organization willing to work with the family with payment options if a scholarship is received?
Scholarship payments will be sent to your organization only AFTER services have been provided.
Your answer
Past progress with this service. *
Your answer
Alternative Sources of Funding *
Required
Why should the student and/or family be considered for a scholarship? *
Please be as detailed as possible.
Your answer
Additional Information
Your answer
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