2024 ASCV Membership Scholarship Application
Thank you for your interest in joining the ASCV! Please complete the form below to apply for a year-long ASCV Membership Scholarship. This scholarship is available for households, self-advocates, and professionals. If you have any questions or need support completing this scholarship application, please email us at info@ascv.org, and we would be happy to help!
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Email *
Name *
Email Address *
Complete Mailing Address *
Phone Number *
Which membership are you interested in? *
Required
Are you a current ASCV Member? *
Demographic Information
This information allows us to know more about our membership base, informs program evaluation and development, helps us determine which programs might be of interest to you and your family, and ensures we are providing appropriate services and supports. We will not share your personal information.
Please list the name and DOB for each family member with autism.  *
Please list the name and DOB for other family members.
Race/Ethnicity (Providing this information is optional. This information is collected for grant purposes only, and is reported in aggregate, not individually) 
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Household Income Bracket (Providing this information is optional. This information is collected for grant purposes only, and is reported in aggregate, not individually) 
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How did you hear about us? *
Is there anything else you would like us to know about you and/or your family? *
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