2019 Individual Enrichment Grant Application

The Autism Society of Nebraska is pleased to provide grant opportunities to help enrich the lives of individuals on the Autism Spectrum. The Individual Enrichment Grant is administered by the Autism Society of Nebraska. Grants in the amount of $100 are available. Individual Enrichment Grant funding is designed to help supplement therapies, equipment, items, lessons or activities to enrich the life of a person with Autism.

Please read the following carefully and complete the application.

Eligibility Requirements:

- Have a medical diagnosis or school verification of autism

- Live in the state of Nebraska

- Be a member of the Autism Society of Nebraska

If you are not a current member: By completing this application you will automatically become a member of the Autism Society for 2019 and are agreeing to the terms of membership. Membership is free for the duration of 2019. For more information on ASN memberships, please go to http://autismnebraska.org/membership/

Applicants are eligible once per calendar year. If there are multiple individuals in a family with an ASD, an application for each member will be accepted. Individual Enrichment Grants may NOT be used for conference registrations. Please submit the Conference Grant application to help with conference fees. Erroneous or incomplete applications may negate award. You will receive communication from us via the email you provided within 30 days of application submission.

In order to help us demonstrate the importance of this program to our donors, we ask that you please provide a photo or written thank you demonstrating how these funds helped meet the needs for you and your family. Please send the thank you to Autism Society – Enrichment Grant, PO Box 83559, Lincoln, NE 68501-3559.

Grant awards are at the discretion of the Individual Enrichment Grant Committee and the Board of Directors of the Autism Society of Nebraska. Awards are based on eligibility, position, merit, and the number of applications received. Any deviation of criterion or process is at the discretion of Autism Society of Nebraska Board of Directors and will require a majority vote. Completion and submission of the grant application to meet the regular requirements is entirely the responsibility of the applicant.

Any questions should be directed to the Autism Society of Nebraska at

1-800-580-9279 or autismsociety@autismnebraska.org

Thank you for your interest and support!

Question Title

* 1. Name of Individual with ASD

First Name

Last Name

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* 2. Application Completed By

First Name

Last Name

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* 3. Relationship to Individual (or self)

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* 4. Diagnosis of ASD

School Verification

Medical Diagnosis

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* 5. Address of Individual with ASD (check will be mailed here)

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

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* 6. Email (this is how you'll be notified)

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* 7. Primary Phone Number (xxx-xxx-xxxx)

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* 8. Kind of Phone

Home

Mobile

Work

Other (please specify)

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* 9. Please provide a brief description of your need for this grant

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* 10. Other relevant information

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* 11. By completing this application, I am aware I will become a member of the Autism Society of Nebraska for 2019 at no cost.

I agree

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* 12. I’ve read the above guidelines for the Individual Enrichment Grant and agree to the terms.

I agree

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* 13. Electronic Signature

First and Last Name