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CENTRAL INDIANA CHAPTER-ASA

Summer Camp Scholarship Application

Purpose:  To enable a member of the CIC-ASA with a child or adult with autism to attend a summer camp.

Amount of scholarship:  $100.00

Number of scholarships available:  Thirty, but not to exceed $3000.00 in total expenditure.

Deadline:  Application due ASAP and will be accepted until all 30 scholarships are awarded.  Scholarships will be determined on a first come, first served basis. 

Mail completed form to:      Central Indiana Chapter - ASA

                                                P.O. Box 50534

                                                Indianapolis, IN   46250

For more information, email Debbie Myers:  emyers4@earthlink.net or call (317)842-4280

*        *        *        *        *        *        *        *        *

Name of person with autism:  _______________________________________________

Parent/guardian name:  ____________________________________________________

Address:            ____________________________________________________________

                        ____________________________________________________________

Telephone:  _____________________________________________________________

Summer Camp name:  ____________________________________________________

Camp address:  __________________________________________________________

Camp Telephone number:  _________________________________________________

Dates of Camp session:  ___________________________________________________

Total Cost:  _____________________________________________________________

Other comments:  ________________________________________________________

****IF CHECK IS TO BE MADE OUT TO FAMILY PLEASE ATTACH COPY OF RECEIPT FOR CAMP PAYMENT***