Please send this application and your registration form at least one month before your registration
deadline to: Delco Family PASS
PO Box 210
Drexel Hill, PA 19026
The executive committee will review all applications and notify you of our decision within two weeks.
If your scholarship is approved we will issue a check to you made out to your event which will not
exceed ½ of the total conference fee or $200.00 .
We have a limited budget for scholarships. Every effort will be made to ensure that our funds are
distributed equitably. We can not guarantee that everyone who is eligible for a scholarship will receive one.
Name___________________________________________________________________________
Address__________________________________________________________________________
__________________________________________________________________________
Phone Number (Daytime) ________________________________(Evening) ____________________
Eligibility
Please answer yes or no to the following questions. Applicants are required to be a family member or
guardian of a person with an Autism Spectrum Disorder and live in Delaware County.
1. Do you have a family member with autism? Yes / No
2. Do you reside in Delaware County? Yes / No
3. Have you attended at least three support
group meetings in the past year? Yes / No
4. Are you a member of the listserve? Yes / No
5. Are you the parent of a newly diagnosed child? Yes / No
6. Have you already received a scholarship this year? Yes / No
(there is a limit of 2 scholarships per person, per year)
7. Are you willing to share what you learn at this conference
with the support group? Yes / No
Where would you like to go?
Please tell us about the event you would like to attend.
1. Name of event:
2. Date:
3. Contact information (please enclose a copy of your registration form)
4. Briefly describe how this conference will benefit your family member with autism
deadline to: Delco Family PASS
PO Box 210
Drexel Hill, PA 19026
The executive committee will review all applications and notify you of our decision within two weeks.
If your scholarship is approved we will issue a check to you made out to your event which will not
exceed ½ of the total conference fee or $200.00 .
We have a limited budget for scholarships. Every effort will be made to ensure that our funds are
distributed equitably. We can not guarantee that everyone who is eligible for a scholarship will receive one.
Name___________________________________________________________________________
Address__________________________________________________________________________
__________________________________________________________________________
Phone Number (Daytime) ________________________________(Evening) ____________________
Eligibility
Please answer yes or no to the following questions. Applicants are required to be a family member or
guardian of a person with an Autism Spectrum Disorder and live in Delaware County.
1. Do you have a family member with autism? Yes / No
2. Do you reside in Delaware County? Yes / No
3. Have you attended at least three support
group meetings in the past year? Yes / No
4. Are you a member of the listserve? Yes / No
5. Are you the parent of a newly diagnosed child? Yes / No
6. Have you already received a scholarship this year? Yes / No
(there is a limit of 2 scholarships per person, per year)
7. Are you willing to share what you learn at this conference
with the support group? Yes / No
Where would you like to go?
Please tell us about the event you would like to attend.
1. Name of event:
2. Date:
3. Contact information (please enclose a copy of your registration form)
4. Briefly describe how this conference will benefit your family member with autism
| Delco Family PASS Delaware County Family PDD/Autism Spectrum Support Johnny Bellopede Scholarship Application |
