Description and Purpose

Description and Purpose

Financial support is offered to ensure that individuals who would otherwise find it a financial hardship to attend aprogram are able to participate and learn from the experience. All recipients are responsible for their food, lodging, and ground transportation expenses if applicable.

Preference will be given to applicants who have not received financial support in the past three years. Incomplete applications will not be considered.

Please note the deadline and submission dates and anyadditional requirements if any.

Eligibility Criteria

To be eligible to receive PALS financial support, applicants must:

Be registered with UCF-Center for Autism & Related Disabilities (UCF-CARD), at least 6 months, as an individual with autism or a parent of an individual with autism.
UCF-CARD file updated with diagnosis, address and contact information.

Commit to fully participate in the education programs funded by the scholarship.

Make your own travel and accommodations arrangements if applicable.

Commit to attend once selected, except in the case of a family or personal health emergency.

Cancellations must be communicated to PALS as soon as possible to make the scholarship

available to another applicant.

CONFIDENTIAL DATA – MUST BE COMPLETED IN FULL. IF NOT USING A COMUTER.

PLEASE PRINT CLEARLY

THIS REQUEST IS FOR THE 25TH ANNUAL CARD CONFERENCE

(Please fill out all that is applicable to the person requesting the support. If a question does not apply to the applicant simply put NA in the box)

SECTION I

Applicant Name:Date of Birth:

Are you an independent adult? Yes No

Address:

City: State: Zip:

Phone: Email:

UCF CARD Coordinator’s Name:

Have you been granted financial support from any PALS program before? Yes No If Yes, when and for what program?

SECTION II

EMPLOYMENT

Family/Individual Adjusted Gross Income (AGI)(as reported to IRS*)

less than $20,000$20,000-$29,000$30,000-$39,000 $40,000-$49,000 $50,000-$59,000 $60,000-$69,000 $70,000-$79,000$80,000-$89,000 More than $90,000

How many people does this income support? . List ages of other siblings

Occupation- Father Currently employed?Yes No

Occupation – Mother Currently employed?Yes No

Current Employer of Father:

SECTION III

Do you receive free or reduced lunch from the school system? Yes No

Do you receive food stamps/SNAP? Yes No

Do you/ or your child receive the Medicaid Wavier? Yes No

Please list any types of State or Federal Support received:

*Please note we may request a W-2

SECTION IV

We would like to know more about you or your child’s desire to attend. Please write a brief paragraph below, and please include the following:
Why do you or your child want to attend this program?
How do you believe this experience will benefit you or your child?
What alternative resources have you requested financial support from prior to PALS? (i.e. your church, your school ESE district, FDLRS, family, etc.)
Explain why you are requesting Financial Support. Please include special circumstances, such as unemployment, unreimbursed medical expense and other factors that will help us make a fair decision.

The financial support committee will reviewapplications and make a decision within a week to ten days of receipt. We will notify you by e-mail (or letter) of the amount that you were awarded.

By submitting this Application, the undersigned Applicant (i) represents that the information and documents provided herein or attached hereto are true, correct and complete, (ii) authorizes PALS to verify the accuracy of all information and documents provided herein or attached, and authorizes and directs all third parties to provide PALS with any and all information regarding the information provided herein, (iii) acknowledges that the submission of this application does not guarantee that applicant will receive any assistance from PALS, (iv) represents that the applicant has not already received or does not anticipate receiving any scholarships or other forms of financial assistance not otherwise described in this application, (v) represents that applicant is not related to any of PALS’s officers, directors or members of the Scholarship Committee, (vi) will use all awarded financial assistance for the intended purposes and will supply PALS with documentation of such use in the form requested by PALS, (viii) understands that the applicant is responsible for determining whether any financial assistance provided by PALS is

subject to federal, state, or local income tax, and (ix) understands and agrees that in the event Applicant’s representations herein, or documents attached hereto, are inaccurate, or Applicant intentionally submits false, incomplete or misleading information or documentation, Applicant immediately will return all funds provided and Application may be subject to criminal prosecution. The undersigned further acknowledges his or her understanding that any award and continuation of financial assistance from PALS shall be conditioned upon, in addition to the other factors described in the Scholarship Guidelines, as determined by PALS within its absolute discretion.

Your signature on this agreement form confirms that you have read the PALS Financial Support requirements and, if selected, commit to fully participate in the program provided under the granted support. You understand that by typing your name in the signature potion is the same as signing your signature.

Name of Registered ConstituentSignature of Parent /Guardian/Adult w/ASD

Date:

Providing Autism Links & Support, Inc. is a public charity open to all applicants, and it does not discriminate based upon any criteria prohibited by law. Applications and inquiries should be sent to PALS, P. O. Box 781458, Orlando, FL 32878-1458.

For Committee Use Only

Date reviewed:______accepted rejected

Signature of Committee Member:______

Date:______

Submit application form and other requirements by email to or mail to

PALS. PO Box 781458. Orlando, FL 32878-1458 or fax 407.823.6012.

The decision to make scholarship fund distributions is made by the scholarship committee, upon which no director or officer of PALS may sit (the “Committee”). The award of scholarship funds shall be based on (i) the nature of the particular program or course the applicant seeks to attend, (ii) the applicant’s need for financial assistance to attend the particular program or course, and (iii) the identity of the applicant, with preference given to individuals with autism, family members of children with autism, professionals working with children with autism or in related fields, and students studying in fields related to children with autism. Consistent with Revenue Ruling 56-304, 1956-2 C.B. 306, PALS shall maintain an individual case history of every Application received (whether accepted or declined), and shall maintain records evidencing the applicant’s financial need and use of the scholarship funds (if awarded). In order to avoid any appearance of self-dealing, grants shall not be made to any officer or director of PALS, or any member of the Committee, or their respective, immediate family members. PALS shall not discriminate in favor of or against any eligible individual on any basis, including race, religion, sex, national origin or place of employment.