Kay Ness Neurodevelopmental Scholarship Application

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To apply for this program please complete the application below. Priority will be given to members who have been active with The FOUNDATION.

In order to receive a scholarship, you must first contact Linda Kane and be on her schedule. http://senc.us/

PARENT INFORMATION

First Name: *

Last Name: *

Address 1: *

Address 2:

City: *

State: *

Phone Number: *

Email: *

APPLICANT INFORMATION

Child's First Name: *

Child's Last Name: *

Age: *

PROGRAM INFORMATION

Has your child been evaluated by a Neurodevelopmentalist (ND)? *

No, my child has never had an ND evaluation and I am requesting the initial eval ($675).

Yes, my child has been evaluated by an ND and I am requesting a follow-up appt ($600).

If you are requesting a follow-up appointment, please provide the date of your last eval.

What are the areas you are most concerned about? *

I have attended a training/seminar by Linda Kane.

I have listened to Linda's "Audio Seminar' explaining the ND Program.

I have not attended training or listend to Linda's seminar..

If you have had a previous evaluation please answer the following questions.

In what ways has the program benefitted your child?

What areas do you feel you need the most assistance with?

How many days per week on average are you able to work on any part of your program plan?

Which specific activities do you find easiest to implement?

Do you have a therapist or tutor assisting you in implementing this program plan? *

Scholarship Amount

Please let us know the scholarship amount required. Maximum amount for first visit is $340. Follow up
appointments can request any amount necessary for your family to participate. It is not guaranteed you
will receive the full amount requested. It is our goal to allow as many families as possible to participate
so we will do our best to accommodate every need. Please take into consideration if you can afford to
pay for a portion of your evaluation, that will allow another family the opportunity to participate.

I do not need a scholarship.

I need a partial scholarship.

Requested scholarship amount: *

First time families maximum scholarship amount is $340. If you do not need a scholarship please enter $0.

Other Information

Comments:

I am a member of The Foundation.

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This form was created inside of Down Syndrome Foundation Of Florida.