Family Scholarship Program Application Therapy orTreatment Scholarship TACA Philadelphia Chapter biomedical treatment for their child maximum request 280 Applicant Name Last First CHILD INFORMATIO ID: 853699
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1 TACA Family ScholarshipApplicationTherap
TACA Family ScholarshipApplicationTherapy or Treatment Scholarship TACA Philadelphia(Rev Family Scholarship Program Application Therapy orTreatment Scholarship TACA Philadelphia Chapter biomedical treatment for their child maximum request $280 Applicant Name (Last, First) CHILD INFORMATION : Do you have a child with autism spectrum disorder living with you? When was the child diagnosed? _________________ How long have you been doing biomedical treatments? ____________Do you have MORE THAN ONE child with autism spectrum disorder living with you? Yes No (If yes, how many? Please also provide their ages and diagnosis.) MARITAL STATUS : Are you married? If you are a single parent, do you receive monthly child support? Yes No If yes, how much $__________ INCOME: What is your combined household income? __________________________ INSURANCE: Do you have health insurance for your family Yes Type: _______________________ No SERVICES: TACA ASSSITANCE: Have you ever received assistance from the TACA bef
2 ore? If so, please note the amount, for
ore? If so, please note the amount, for what and when. Yes No TACA Family ScholarshipApplicationTherapy or Treatment Scholarship TACA Philadelphia(Rev Family Scholarship Program Application Therapy orTreatmentScholarship TACA Philadelphia Chapter CHECKLISTAPPLICATION IS NOT COMPLETE WITHOUT THE FOLLOWING Proof of diagnosis. Date you became a TACA Member.(Join online now if not already a member) Name of camp you would like your child to attend Cost of camp (maximum scholarship is $280) DEADLINE APRIL 1, 2012 All information submitted to TACA shall remain confidential . Please note that, pursuant to Californiaand Federal aw requirements, TACA reserves the right to follow up to ensure any approved grant was actually used for its intended purpose. I certify that the information on this form is true and complete to the best of my knowledge.Applicant SignatureDatePlease include the following with this application and mail to TACA Families in Scholarship Program2222 Martin Street, Suite 140, Irvine,CA