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Applicants of all economic levels are welcome to apply for a HALO scholarship.
Please apply online or via the downloadable PDF form and email to amanda@halodance4autism.org
If you have any questions regarding the application, selection process or distribution please
contact amanda@halodance4autism.org
scholarship_guidelines_and_procedures.pdf
File Size:
146 kb
File Type:
pdf
Download File
FINANCIAL AID SCHOLARSHIP APPLICATION
*
Indicates required field
Name of Applicant who will benefit from this scholarship
*
Date of Birth
*
Gender
*
Male
Female
Diagnosis (e.g. autism, PDD-NOS, Asperger’s, etc
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Date of diagnosis
*
Name and professional credential of person who made this diagnosis (eg, MD, PhD, MSW, etc)
*
Name(s) of Parents(s) or Guardians(s)
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Home Phone
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Cell or alternate phone
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Email
*
Marital/relationship status of parents or guardians
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# of minor children including applicant
*
Occupation of father or guardian
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Employer name and phone number
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Occupation of mother or guardian
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Employer name and phone number
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Please provide a detailed description of the services for which you seek financial aid. Please also list the name of the service provider with the address and phone number including a contact person. If you are chosen, the HALO Foundation will pay the service provider directly. Attach additional pages as needed.
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Provider
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Contact Person
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Provider address
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Provider Phone
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Provider email address (if known)
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Total cost of program
*
FINANCIAL INFORMATION
Please itemize your monthly household, pre-tax income, and expenses.
MONTHLY INCOME
Gross Wages, Salary & Tips
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Spouses Gross Wages, Salary & Tips
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Aid to Dependent Children
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Unemployment Compensation
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Social Security and/or Disability
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Child Support
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Housing Allowance
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Food Stamps/CAL Fresh
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Retirement Income (non Social Security)
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Other Income
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TOTAL MONTHLY INCOME
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MONTHLY EXPENSES
Rent or Mortgage
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Utilities
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Food
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Clothing
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Car Expenses (gas, insurance, loan, etc)
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Other Transportation Expenses
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Medical Insurance
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Medical Expenses
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Other Expenses
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TOTAL MONTHLY EXPENSES
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HOME OWNERSHIP AND OTHER ASSETS AND LIABILITIES
Do you own your home and/or other real estate?
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Yes
No
* If yes, please list each piece of real estate separately with its approximate value.
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Primary home value
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Total mortgages/loans against property
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Other real estate value
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Total mortgages/loans against property
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Do you rent your home?
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Yes
No
If yes, what is your monthly rent?
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Amount in checking and savings account
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Total amount in RETIREMENT ACCOUNTS like IRAs, 401k, 403B, etc. List each account and approximate balance as of the latest valuation date.
*
List other significant ASSETS:
*
List other significant LIABILITIES you owe, for example credit cards
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OTHER CONSIDERATIONS
Medical Insurance coverage:
Company and coverage type
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Monthly Premium
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Will your medical insurance pay for any of the services described in your request?
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Yes
No
If yes, please describe
*
Does your medical insurance cover any therapy for autism?
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Yes
No
If yes, please describe coverage or attached a description provide by your insurance company
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Is your child eligible to receive financial aid from any other agency
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Yes
No
If yes, please provide the name and agency and the amount being received.
*
Please describe how you think this scholarship will benefit you, or any other information that will help us evaluate your application such as impact on your child, financial situation not listed above, or your child’s special needs. Attach additional pages as necessary.
*
Copy of recent federal income tax return for you and/or spouse if applicable
*
Max file size: 20MB
Copy of most recent W-2 for you and/or your spouse if applicable
*
Max file size: 20MB
Copy of medical diagnosis or complete IEP
*
Max file size: 20MB
Submit
Home
Vision
>
Founders VIsion
Foundation Vision
Mission
EVENTS
Scholarship Program
Apply
Meet the Board
High School Halo Clubs
PARTICIPATE
HALO ARMY DANCE COMPANY
Volunteer
Community Blog
Donate
Contact