Stipend Form

The individual requesting a stipend must reside in one of the seven parishes served by Autism Society Acadiana (ASA): Acadia, Evangeline, Iberia, Lafayette, St. Landry, St. Martin, or Vermilion.

Autism Society Acadiana provides stipends in the following categories: EDUCATION, RECREATION and TECHNOLOGY.

Stipends will be provided to *ACTIVE* Autism Society Acadiana members and are limited to the amount in the board approved budget for that category/program each fiscal year.

*An ACTIVE Autism Society Acadiana member is defined as a member who VOLUNTEERS TIME/EFFORT for the organization with fundraisers or chapter-sponsored activities. (Examples include but are not limited to the following: WALK FOR HOPE, FAMILY PICNIC, TRIVIA NIGHT, and CHRISTMAS PARTY. A minimum of (3) volunteer hours in the previous 12 months from date of stipend request is required. Efforts other than actual volunteer hours such as contributions of food, materials and equipment, or services such as ASA office work will also be considered. Volunteer hours will be verified, and final decision of stipend request is discretionary

The Educational Stipend is for ACTIVE Autism Society Acadiana members to attend educational conferences/workshops/seminars, etc. Educational stipends will be limited up to $200.00 per family, per calendar year.

Educational Stipend Guidelines are as follows:

Conferences/Workshops/Seminars

• The person with an autism spectrum disorder (ASD) applying or the parent(s)/caregiver applying
  for the stipend must be an active Autism Society Acadiana member.

• The individual with ASD must have been diagnosed with an ASD by a qualified medical or
  educational professional (school evaluations are acceptable).

• The individual making application for the stipend must be an active Autism Society Acadiana
  member and 18 years or older

Reimbursement Process for Conference/Workshop/Seminar ·

Stipend checks will be made payable to the provider/sponsoring organization and either mailed directly to the provider or organization or mailed to applicant to send in with registration form

Stipend application must be submitted with accompanying documentation regarding conference/workshop/seminar to the Autism Society Acadiana office, via fax, email, or US Postal Mail, well in advance of early registration deadlines. To be reimbursed for payment made for a conference/workshop/seminar, proof of attendance must be submitted or within 14 days following the event.

This stipend is for individuals with an autism spectrum disorder (ASD) that allows participation in a
recreational activity. Previously approved programs include but are not limited to: camps, swimming
lessons, art lessons, karate lessons, dance classes and bowling. Applicant individual or parent(s) must be
an active member of Autism Society Acadiana.

Recreational Stipend Guidelines are as follows:

• The person with an autism spectrum disorder (ASD) applying or the parent(s)/caregiver applying
  for the stipend must be an active Autism Society Acadiana member.

• The individual with ASD must have been diagnosed with an ASD by a qualified medical or
  educational professional (school evaluations are acceptable).

• There are no age limitations for the individual with an ASD to be considered for a stipend. Both
  children and adults are eligible.

• The name and description of the program, along with contact person, mailing address and phone number must be included on the stipend request form. Activities which are not funded by recreational stipends include, but are not limited to: educational classes, tutoring, continuing education, summer school, therapy, counseling, and daycare/babysitting service.

• Recreational stipends for the calendar year will be limited to a maximum of $200.00 per individual and limited to two activities/programs per fiscal year (January - December).

Reimbursement Process for Therapeutic Equipment or Assistive Technology Device

Reimbursement will be made to applicant upon submission of proof of payment for the equipment/device. A stipend application request for partial/full reimbursement of purchase of equipment or technology device must be made within 30 days of purchase. Receipt of purchase is required. No exceptions. For payment to be made to provider or company for the purchase of the equipment/ device, arrangements must be made with our office staff once stipend is approved.

By checking this box I agree to the below statements.

I have read the educational/recreational/technology stipend guidelines for which I am applying and fully understand the guidelines and attest to the number of volunteer hours/efforts I have stated on the stipend request form being submitted to Autism Society Acadiana for review and approval. manner applied for it is the responsibility of the applicant to contact the ASA office at [email protected].

Date:

Note: The above stated guidelines are provided for general purposes. Autism Society Acadiana does recognize that there occasionally are individual extenuating circumstances. Requests for consideration of special circumstances should be submitted to the Autism Society Acadiana office for Budget Committee to review.

Member (Parent/Caregiver Name):*

SS# or EIN/Tax ID# of person/entity requesting funds:*

Street Address:*

City, State, Zip Code:*

Email Address:*

Name of person with Autism Spectrum Disorder:*

Diagnosed By (school professional, doctor, etc):*

Contact Information of Professional:*

Recreation/Education Activity Attending:

Date(s) of Activity: Location:

Registration Fee: Stipend Amount Requested:

Recreation Item(s) & Price(s):

Where can item(s) be purchased?:

OR

Therapeutic Equipment/Assistive Technology Device:

Professional Recommeding Equipment/Device: Date Purchased: