SCHOLARSHIP APPLICATION

We are happy that you have chosen to apply for a full or partial scholarship to attend our event!

We feel that no barrier should come between sharing the important information and experience that is this important information.

Please answer the following questions. Shortly following your submission, the Lewis County Autism Coalition will reach out to you

to discuss next steps.

Can't wait to meet you!

First name

Last name

Street Address (or) P.O. Box

City, State

Zip Code

Phone

Yes, subscribe me to your newsletter.

What is the name of the event you seek a scholarship for?

INTEREST IN THE EVENT: Why are you interested in participating? Please share about your family, your child's age(s), needs (Diagnosis if any, behaviors, challenges, concerns), or anything else you feel is important for us to know.

FINANCIAL NEED: Please describe your financial need for this scholarship?(Please limit your response to 150 words.)

Are you requesting a FULL or PARTIAL Scholarship? If you are able to contribute any portion of the admission cost, please include the dollar amount below.

Do you require any special accommodations (i.e., translator, seating, other) If no, write N/A. If yes, please describe.