Direct Help Grant Application

Thank you for participating in our Direct Help Program. Our mission is to provide services, medical necessities, and educational tools to families who live in Central California that are affected by Autism. Please fill out this application in its entirety before submitting.

Privacy Statement:

The information included in this application will remain private and confidential and is used for Foundation use only.

Child with Autism (if requesting aid for more than one child, please fill out a separate application):

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Child's Information
If requesting aid for more than one child, please fill out a separate application.

Mother/Legal Guardian

Father/Legal Guardian

Shipping Address (If different from mailing address)

Dependent Children Information

Doctor(s) Involved In Child's Diagnosis and/or Treatment of Autism

Requested Items to Be Purchased by Foundation if Grant is Awarded
Note: Please be very specific with your description of monetary help or items needed for your child. At no time will money be awarded directly to families. All grant offerings are paid directly to the vendor and/or service provider. This may include tuition for specific classes, supplements/medication, medical evaluations, learning materials, testing, therapies, etc. The maximum amount awarded per child is $500 per calendar year.

Previous Grants

Future Correspondence

Required Documents
This application will not be considered until all supporting documents are received. Please reassure that ALL NECESSARY documents are uploaded.

All Legal Parent/Guardian Must Print Name Below. All Printed Names are Considered Signatures.

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