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2018 APPLICATIONS ARE DUE MARCH 25, 2018

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 info@halodance4autism.org

If you have any questions regarding the application, selection process or distribution pleasecontact tara@halodance4autism.org

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 *

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) *

Home Phone *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell or alternate phone *

Email *

Marital/relationship status of parents or guardians *

# of minor children including applicant *

Occupation of father or guardian *

Employer name and phone number *

Occupation of mother or guardian *

Employer name and phone number *

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. *

Provider *

Contact Person *

Provider address *

Provider Phone *

Provider email address (if known) *

Total cost of program *

FINANCIAL INFORMATION

Please itemize your monthly household, pre-tax income, and expenses.
MONTHLY INCOME

Gross Wages, Salary & Tips *

Spouses Gross Wages, Salary & Tips *

Aid to Dependent Children *

Unemployment Compensation *

Social Security and/or Disability *

Child Support *

Housing Allowance *

Food Stamps/CAL Fresh *

Retirement Income (non Social Security) *

Other Income *

TOTAL MONTHLY INCOME *

MONTHLY EXPENSES

Rent or Mortgage *

Utilities *

Food *

Clothing *

Car Expenses (gas, insurance, loan, etc) *

Other Transportation Expenses *

Medical Insurance *

Medical Expenses *

Other Expenses *

TOTAL MONTHLY EXPENSES *

HOME OWNERSHIP AND OTHER ASSETS AND LIABILITIES

Do you own your home and/or other real estate? *

Yes No

* If yes, please list each piece of real estate separately with its approximate value. *

Primary home value *

Total mortgages/loans against property *

Other real estate value *

Total mortgages/loans against property *

Do you rent your home? *

Yes No

If yes, what is your monthly rent? *

Amount in checking and savings account *

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 *

OTHER CONSIDERATIONS
Medical Insurance coverage:

Company and coverage type *

Monthly Premium *

Will your medical insurance pay for any of the services described in your request? *

Yes No

If yes, please describe *

Does your medical insurance cover any therapy for autism? *

Yes No

If yes, please describe coverage or attached a description provide by your insurance company *

Is your child eligible to receive financial aid from any other agency *

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

DOWNLOAD APPLICATION

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Home
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Scholarship Program
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