Family Scholarship Fund Application

Please complete the requested information and sign below. You must attach a copy of the previous year's income tax return in order to have your application considered for these funds. Any information you provide is confidential.

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Child's full legal name:

Full legal name of parent/guardian:

Relationship to child:

I certify that the information provided below is true and correct to the best of my knowledge.

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Total annual household income:

Total number of family members:

Address:

Phone number:

Date of application:

M-D-Y

Please attach and upload a copy of your most recent income tax return:

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Additional information you would like to be considered:

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FAMILY SCHOLARSHIP FUND POLICY

The Family Scholarship Fund (FSF) applies to qualifying families receiving services from the UW Autism Center.

Services Covered by FSF
FSF assistance applies to the following services within the UW Autism Center: diagnostic evaluations, speech and language evaluations & therapy, social skills group sessions, behavioral consults, school consultations, home visits, early intervention treatment, program writing and training charges. The FSF may also be applied to the required deposit for diagnostic evaluations. The FSF cannot be used to assist with charges for services provided by medical professionals affiliated with the UW Autism Center. The services by these providers are charged separately through Children's University Medical Group (CUMG).

Use of Funds
All information regarding family income and circumstances will be kept confidential. Families whose income falls within the FSF parameters of the FSF may qualify for reduced fees for services on a first come, first serve basis. FSF is not retroactive the use of funds may only be applied toward services provided after the date of approval.
The FSF program is always subject to available funds. FSF is available for the maximum of TWO terms in a life time. The funding of this program is provided by reservation of a portion of the net income received during the previous year and through annual fund-raising, and thus may fluctuate from year to year. Family Scholarship Funds will not be available after the annual allocation has been dispersed. The amount of funding available is determined at the beginning of each fiscal year and is based on the funds received for this purpose during the previous year.

Ongoing Process
FSF recipients will be required to pay at time of service at each visit for non-covered services. For diagnostic evaluations FSF recipients may set up a monthly payment plan (if FSF does not pay in full). Payment must be made monthly. FSF recipients must comply with all UW Autism Center billing policies in order to maintain funding. If these policies are not adhered to, participation in the Family Scholarship Fund program will be forfeited. The UW Autism Center's Policy and Procedure for Collections is applicable to these accounts, and any decision of termination will be made by the director of the UW Autism Center.

If you are unable to complete this form electronically, please email us at apex@uw.edu and we can send you a PDF copy.

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