Electronic Device Form

Information for this form can be gathered from the child’s parents, teacher, AT specialist, physician or any other professional that can explain how this electronic device will directly help with the child’s autism. Please fill out this application in its entirety and remember to print clearly as illegible applications cannot be considered.

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Note: This device is to be used solely to help the individual with Autism named on the application and not for family members to use for personal reasons.

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Name of People who helped to complete these questions:

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