Scholarship Application Meet the service providers 1Recipient Information2Contact Info3Contact Address4Reason for Applying5Disclosure & Signature I am filling this out for:(Required)Please SelectMyselfMy child/wardRecipient Name(Required) First Last Parent/Guardian Name(Required)If applicable First Last Preferred Communication Methods(I.E. English, Spanish, sign language, PEC board, Proloquo2Go, etc. or any other alternative or augmentative communications. Please explain here.)Recipient Date of Birth(Required) MM slash DD slash YYYY Contact InformationPhone(Required)Email(Required) Preferred Contact Method Phone Call Text Email Contact TimeMorning (9AM - 12PM)Afternoon (12PM - 3PM)Evening (3PM - 6PM) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ReasonHow would you most benefit from this scholarship?(Required)Tell us about what your goals would be from this program.(Required) Disclosure and SignatureDisclosure I certify that Autism Awareness Shop Tampa may use the information provided as part of the selection process for eligibility. (Name, phone number, email, reason for applying)Recipient Signature(Required)Parent/Guardian Signature(Required)
