bureau of autism services and mini rgrant application packet€¦ · bureau of autism services 2012...

Bureau of Autism Services2012 Family and Individual Mini Grant

Application Packet

Table of Contents

Frequently Asked Questions, FAQs 2Application Directions 10Mini Grant Application 13

www.dpw.state.pa.us

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The Bureau of Autism Services of the Pennsylvania Department of Public Welfare is pleased to announce theavailability of mini grants to support children and adults with an autism spectrum disorder, ASD, and families thatinclude an individual with ASD.

A focus of this project is to reach out and serve individuals and families that are not able to access existing supportsystems for various reasons (for example: eligibility criteria, age, waiting lists). The term �“family�” may include animmediate family member or other relative, a person providing foster care or a legal guardian or custodian, but doesnot include a person or entity who acts in a paid employment capacity. These grants are funding opportunities thatwill only be offered once and are time limited.

Applicants meeting eligibility requirements may apply for up to $500 in grant funds. Priority will first be given toapplicants age 18 or older who did not receive a Bureau of Autism Services Mini Grant in any previous funding year(2007 2011). Priority will then be given to other individuals who did not receive funding in previous years. Totalfunding for these mini grants is limited and is on a first come, first served basis. Not everyone who applies for thisgrant will be funded.

In order to be eligible, applicants must:

1. Be a Pennsylvania resident.

2. Have a family member with autism (of any age) or be an individual with autism.

3. Not be currently receiving and/or enrolled in any family support services for the past 12months.

2012 Family and Individual Mini Grant ProgramFrequently Asked Questions

1. What is a grant?A grant is a form of state funded aid that does not need to be repaid.

2. Why is the Bureau of Autism Services making this program available?The Family and Social Issues Subcommittee Report of the Autism Task Force recommended thecreation of services and support systems specifically for persons with autism and their familiesthroughout the lifespan (especially including family support services and respite). Although not along term solution, this mini grant program is designed to serve individuals and families who havenot been able to access existing family support systems.

3. Where do I get an application?The application form is available for downloading and printing on the Bureau of Autism Serviceswebsite at www.autisminpa.org or http://bastraining.tiu11.org.

If you don�’t have access to a printer to print the application, please call the Mini Grant Help Line,toll free, 1 866 539 7689, or email DPW [email protected] to request an application packet bymail. Please include your name, complete mailing address and a phone number with area code.

Bureau of Autism Services P.O. Box 2675 Harrisburg, PA 17105 1.866.539.7689 FAX: 717.265.7761DPW [email protected] www.autisminpa.org www.dpw.state.pa.us

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http://www.dpw.state.pa.us/Disable/AutismServices

http://bastraining.tiu11.org/

mailto:[email protected]

4. What are the important deadlines and dates?

Deadline for submission of application (date bywhich applications must be postmarked)

April 15, 2012

Dates during which the activity/support beingfunded must occur

March 1, 2012 through August 31, 2012

Notification of grant awards (by mail) on a rollingbasis

Beginning on or about May 16, 2012 and continuinguntil June 30, 2012

Reimbursement forms due (date by whichreimbursement forms must be postmarked)

September 10, 2012

Funding/checks for awarded grants mailed on arolling basis

Beginning approximately May, 2012 continuingthrough approximately September, 2012

5. Where do I send the application?Mail the completed application to:

Attn: F & I Mini GrantBureau of Autism ServicesPennsylvania Department of Public WelfarePO Box 2675Harrisburg, PA 17105 2675

6. Can I fax or email my application?No. Grant applications must be mailed to the address provided above. Applications received byemail or fax cannot be considered and will be shredded. The Bureau is unable to contact applicantswhose applications are not submitted correctly.

7. What has to be submitted with the application? Documentation supporting the cost of the event/activity for which funds are requested

(brochure, printout from internet, statement on sponsoring organization letterhead, etc.stating cost)

Verification of an ASD diagnosis by a Medical Professional (For clarification of �“Verificationby Medical Professional�” please see question 23.)

Only completed applications will be eligible. The Bureau of Autism Services is unable to contact applicants whose applications are not

complete.

8. Who is eligible to apply? Adults with an autism spectrum disorder, ASD Individuals who have a family member with ASD (of any age) The individual with ASD, and the person completing the application, must be Pennsylvania

residents Individuals not currently receiving and/or enrolled in (or have received/been enrolled within

the past 12 months) any family support services, including waiver funded services, FamilyDriven Support Services, services funded under Individual Support Plans, county basedfunds from MH/DS or other similar services or funding. The Bureau of Autism Services


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reserves the right to and may verify the services and/or funds that the individual with ASD isreceiving.

Families whose family member with ASD is receiving BHRS/Wraparound, Family BasedTherapy or Early Intervention services are eligible for this grant.

The Bureau of Autism Services reserves the right to verify the services and/or funds that theindividual with ASD is receiving.

9. How do I know if I�’m receiving family support services, funding through the Intellectual Disabilitiessystem, or respite funds?If you are not sure what services and/or funds you are receiving please check with your MH/DS casemanager at the county level.

10. What if there is more than one person with ASD in the family? A separate application must be sent for each person with ASD. Do not submit an application

with more than one named individual with ASD. Each application must include complete applicable documentation even if requests are

identical.

11. Are there any income limits for eligibility for this grant?No.

12. What can funds be used for?

THE FOLLOWING ARE AVAILABLE FOR ALL GRANT APPLICANTS, OF ANY AGE (Children or Adults)

Respite care: services may be informal and do not need to be through a respite care agency �–e.g. care can be provided by a private caretaker or a family member who does not reside withthe individual with ASD.

Summer recreation and skill development programs (excludes academic skill development ortutoring programs).

Autism or advocacy related conferences, workshops or training opportunities (includingregistration fees, reasonable accommodation expenses, and reasonable costs for publictransportation). Meal expenses will not be reimbursed. Please note that accommodation andtransportation costs will be paid for via reimbursement with proof of payment required.Transportation costs may not exceed 25% of the total requested grant amount.

Community programs (e.g. karate lessons, swimming lessons, dance classes, art classes, cookingclasses, private driving lessons, etc.). Please note that requests for gym or pool membershipswill be covered for individuals with autism but not for other family members.

Modifications or adaptations for home and/or community for safety (for example: door locks,alarms, fencing or other items to increase or insure safety).

THE FOLLOWING ARE AVAILABLE ONLY FOR GRANT APPLICANTS AGE 18 OR OLDER (Must be age 18 by4/15/2012)

College level coursework Funding will be provided on a reimbursement basis for courseworkcompleted (for credit or non credit) at an accredited college or university. The majority of thecourse must occur during the grant funding period (March 1, 2012 August 31, 2012). Springsemester courses as well as summer session courses would be eligible.

Personal job coaching ONLY AVAILABLE IF SERVICES THROUGH THE OFFICE OF OCCUPATIONALAND VOCATIONAL REHABILITATION, OVR, and/or THE DEPARTMENT OF PUBLIC EDUCATIONHAVE BEEN EXHAUSTED. Supporting documentation must be provided.

Public transportation to organized support group meetings, organized social activities,community programming, conferences or trainings, or place of employment. Please note thattransportation will be paid for via reimbursement with proof of payment required.

13. Can I use the funding for a yearly membership, for example, to a pool or a gym?Yes, however, the funding can only be used to cover up to 50% of the yearly membership dues.Please submit documentation of the full year membership cost, and provide a receipt. BAS willadjust the amount awarded for the membership during the approval process.

If the cost of 50% of the annual fee is less than $500, you may apply for additional activities. Simplylist each activity and its cost in Section C of the application (Funding Request Chart). In this caseonly, the amount in the TOTAL column may exceed $500. BAS will adjust the final amount awardedso that the total amount of the grant does not exceed $500.

14. Do camps and recreation services need to be autism specific?No. Inclusive activities are encouraged. Autism specific or specialized programs are also eligible.

15. What can the funds NOT be used for?The following is a list of items or activities that would be considered ineligible for the grant funding.It is not an exhaustive list; there may be other activities that are not covered.

Extended School Year Programs �– These are funded through the PennsylvaniaDepartment of Education

Medical/psychological/psychiatric evaluations Tutoring Educational materials such as books, workbooks, educational toys, etc. Computers, laptops, tablets, PDA devices, iPads, etc. Therapies such as speech therapy, occupational therapy, physical therapy, and/or

evaluations for speech therapy, occupational therapy, or physical therapy Therapeutic items for speech therapy, occupational therapy, or physical therapy such as

trampolines, weighted vests, etc. Diapers Vitamins and supplements Special diet items Furniture (replacement) Musical instruments Art supplies/material fees Clothing, including uniforms for sports or activities (karate, dance, etc.) �“Test fees�” for sports or activities (karate, dance, etc.)

16. What if the cost of the support or activity for which I am applying for funding exceeds $500?You can still apply, but you will need to fund the difference between the grant amount and the costof the support/activity. In the �“Cost of Support/Activity�” column, please only put a cost of up to$500 even if the cost of the support or activity exceeds $500.


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17. Can I request funds for more than one support or activity?Yes. The grant funds can be used for as many eligible supports/activities as you like, as long as thetotal amount requested does not exceed $500.

18. If I am requesting respite or caretaking services how do I document it on the application?Please fill in the �“Respite�” section on the bottom of the �“Funding Request Chart�” document and fillout as much information as you know at the time of application. Be sure to include the totalamount requested for the services. If you are awarded the grant you will be mailed a separate formthat you and the provider of the service will need to fill out in order for you to be reimbursed.

19. How can I use the funds to pay for a private respite or care provider?This type of service will be paid for by reimbursement, with proof of payment required. The granteewill be required to complete and submit a �“Reimbursement Form for Respite/Child Care Services.�” Ifyou are awarded a grant, the required form will be sent to you at that time. This form must besigned by the provider of the service. You will then be reimbursed for the cost of those services.

20. Can I still apply if my family member with ASD does not live with me? Do I have to be theindividual�’s legal guardian?You can apply on behalf of a family member with autism who does not live with you. Anyone who isrelated (by marriage or immediate family) to the individual may apply for this grant on his/herbehalf. A legal guardian may also apply whether or not the person with ASD is a family member.

21. How does the Bureau of Autism Services decide who gets a grant?Priority will first be given to applicants age 18 or older who did not receive a Bureau of AutismServices Mini Grant in any previous funding year (2007 2011). Priority will then be given to otherindividuals who did not receive funding in previous years. Total funding for these mini grants islimited and is on a first come, first served basis, and not everyone who applies for this grant will befunded. See Question #22 for our review process.

22. What happens once BAS receives my application?Once your application is received by the Bureau of Autism Services, the process is as follows:

Application is stamped with the date that is postmarked on the envelope BAS checks to see if applicant was funded in a previous grant year

o Priority is given to those applicants who have not previously been funded in anyprevious funding year (2007 2011).

BAS reviews the documentation submitted to verify a diagnosis of ASDo defined as any of the five Pervasive Developmental Disorders listed in the

Diagnostic and Statistical Manual of Mental Disorders IV TR Autistic Disorder (Autism) Pervasive Developmental Disorder, Not Otherwise Specified (PDD or

PDD NOS) Asperger�’s Disorder or Aspergers Syndrome Rett�’s Disorder Childhood Disintegrative Disorder

Application is reviewed to check thato Requested services/activities are eligible requestso All required items on application are completed


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o Supporting materials (brochures, printout from internet, statement onsponsoring organization letterhead, etc. stating cost) for the requested fundinghave been included

Once an application has been approved for funding, grant awardees will be notifiedbeginning May 16, 2012 and continuing on a rolling basis until June 30, 2012.

The Tuscarora Intermediate Unit issues award letters and checks on behalf of BAS. If yourapplication is accepted, your award notification letter will come from the TuscaroraIntermediate Unit, not the Bureau of Autism Services.

The Tuscarora Intermediate Unit issues denial letters on behalf of BAS. If your applicationis denied, your denial notification letter will come from the Tuscarora Intermediate Unit, notthe Bureau of Autism Services. Denial letters are sent to applicants whose applications donot meet the criteria or are missing documentation or supporting materials with a briefindicator of why the application was denied.

Once all funding has been exhausted, letters of denial will be sent to applicants who will notbe receiving the grant funding for this year.

Funding (checks) are sent to the applicant to distribute to service providers orreimbursement forms are sent to the applicant for completion. Once reimbursement formsare returned funding/reimbursement is sent to the applicant (2 3 week turn around time).

All reimbursement forms must be postmarked by September 10, 2012.

23. What will you accept as documentation of an autism spectrum disorder, ASD?A licensed medical professional must complete the Verification of Diagnosis Form OR you mustattach a copy of a report confirming a diagnosis of an ASD. (See Application, Section E)

SUBMIT EITHER:A. The form within the application which has been completed and signed (electronic signatures

and copies of faxed documents are accepted) by a licensed medical professional (familyphysician, pediatrician, developmental pediatrician, neurologist, etc.) or licensed psychologist,licensed school psychologist or licensed psychiatrist). Educational testing is not an acceptableform of diagnosis. Please do not send IEPs or school evaluation reports.

OR:

B. A copy of a report prepared by one of the above mentioned professionals indicating theindividual has an ASD diagnosis. The date that the evaluation was completed is irrelevant. Pleasedo not send an entire evaluation.

We need only the following items:

Cover sheet with demographic information of the individual with ASD on the letterhead ofthe practice or diagnosing agency/professional.

The page which indicates and/or states �“Axis 1 diagnosis�” of ASD or the �“diagnosticimpression�” which clearly states that the individual has a diagnosis of ASD. Additionally, ifyou wish, you may highlight or circle the diagnosis. Please note that a �“Rule Out�” diagnosis isNOT a diagnosis.

The signature page that includes the signature and license number of the licensedprofessional who determined the diagnosis or who can verify that the individual does havean ASD diagnosis (electronic signatures and copies of faxed documents are accepted).


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*Please note that educational testing and records are not an indication of diagnosis and will notbe considered proper documentation for this grant.

Please note that no documents will be returned, so make sure that you keep all originals. Pleasesend only copies.

24. I submitted a mini grant application in a prior year. Do I have to resubmit the �“Verification byMedical Professional�” form?Yes, a new form or copy of a report must be submitted with this application. Applications withoutthis form will not be considered.

25. What do �“modifications or adaptations for home, community or safety�” mean?A modification to your home might be installing special locks or alarms on windows or doors thatyou feel are necessary to keep your family member with ASD safe. Only permanent modificationswill be allowed. A modification might be a specialized bike that allows your family member with ASDto ride, a special booster or car seat that keeps your family member with ASD safe while beingtransported in a motor vehicle. Augmentative Communication Devices are not considered amodification under this category. Proper documentation for a modification or adaptation may be anestimate from a contractor, lumber yard, home store, etc. for the cost of the project that includes anitemized list of materials and costs of materials and labor if applicable. The applicant will beresponsible for the cost of all taxes, applicable permits/fees and shipping costs associated with themodification or adaptation.

26. Do retail stores and online merchants accept the mini grant checks?Many large retail stores, for example, Home Depot, Lowe�’s, Wal Mart, or Toys R Us, will not acceptthird party paper checks, such as mini grant checks. Therefore, items purchased or to be purchasedfrom large retail stores will be funded by reimbursement only. You may provide a copy of a receiptat the time of application, or if you are awarded the grant you will be provided with areimbursement form to use.Please check with any stores, including smaller retail stores or online companies, to be sure theycan accept third party paper checks as payment, prior to submitting your application.

27. How are funds disbursed?The Tuscarora Intermediate Unit issues award letters and checks on behalf of BAS.Wheneverpossible, checks will be made payable directly to the provider of the support or activity and mailedto the applicant. Please make sure that you clearly indicate on your application (Funding RequestChart) exactly who the check should be made payable to in order to avoid delays in funding. It is theresponsibility of the applicant to deliver the check to the provider. For example, if you have beenawarded a grant to fund camp fees, a check payable to the camp will be sent to you and you willneed to deliver the check to the camp (together with any applicable registration forms or additionalpayments due).

28. How long will it take for me to get the funds?Funds will be disbursed on a rolling basis beginning approximately May 16, 2012, and may continuethrough the end of the fiscal year (June 30, 2012). Funds are disbursed on a first come, first servedbasis, so early submission is advised. Priority is given to those who have not been funded in previousfunding years. Reimbursements are distributed as they are received within a 2 3 week time frame.


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29. What if I have already paid for the service/activity?If the activity or support occurs between March 1, 2012 and August 31, 2012 and the applicant has areceipt from the provider, the applicant will be reimbursed directly. Please make sure to include acopy (not originals) of a receipt, invoice marked as paid with the payment method referenced suchas a check number or credit card, or scanned check images (front and back) in place of an actualcancelled check.

30. Are the funds received through the Family and Individual Mini Grant taxable?BAS cannot address questions about taxes. Recipients should consult their tax professional.

31. What if I have other questions?BAS is unable to return calls requesting the status of a grant application. For all other questions notanswered in this document, please email DPW [email protected] or call the Mini Grant HelpLine, toll free, 1 866 539 7689.

Important Notes:

Applications will only be accepted by mail. Faxed or emailed applications will not be considered.

BAS is not responsible for applications returned for insufficient postage, delayed or lost intransit. You may wish to consider sending your completed application via Certified Mail with areturn receipt to assure that our office has received your application.

We encourage you to make a copy of your application and all supporting documents prior tosubmission for your records.

Incomplete and illegible applications will not be considered for funding, so please be sure thatyour application is signed and complete with all necessary documentation attached.

Please remember that you are solely responsible for the completion of this application despiteany assistance that you may accept from third party sources (i.e. case managers, behaviorspecialists, etc.). However, you may wish to consider having a third party review yourapplication to assure that you have met all application requirements and have included allnecessary documentation.

mailto:[email protected]

Bureau of Autism Services MINI GRANT 2012APPLICATION DIRECTIONS

Please print legibly

SECTION A

1. Enter your name where it says NAME OF PERSON COMPLETING THIS FORM.2. Please note, the person completing this form must be 18 years of age or older, i.e. parent,

guardian, or adult with autism applying for himself or herself.

3. Check one box to indicate your relationship to the individual with ASD.

4. Fill in your mailing address, telephone numbers and email address.

SECTION B1. Enter the name of the individual with ASD. If you are filling out this form for yourself, you can

write SAME in this space.

2. Enter the age (as of April 15, 2012) and date of birth of the individual with ASD. Please spell outthe name of the month.Example:

AGE: 19 MONTH: September DAY: 12 YEAR: 1992

3. Enter the name of the county in which the individual with ASD lives.Example: Allegheny, Centre, Bucks

FUNDING REQUEST CHART: SECTIONS C & DYou can copy this page if you need more space to list the supports, activities, or respite you arerequesting grant money for.Please see the FAQs (questions 12 15) for information on what activities or supports can be funded.

SECTION C: Please complete this section for all supports and activity requests, except for respite.

1. Fill in the type of activity or support, the name of the organization who will be providing thesupport or activity, the cost and the dates of the support or activity.

2. Attach documentation stating the cost of the Support/Activity (for example: conferencebrochure, camp brochure, announcement, contractor�’s quote, invoice or recreational programreceipt on letterhead, printout from internet). *Please highlight or circle the cost of the activityon the brochure.

If the activity for which you are requesting funding for will need to be paid prior to theawarding period of the grant (Mid May though June) you may wish to consider paying upfront and requesting reimbursement by submitting receipts to avoid a delay in funding.

If payment has been or will be made before May 16, 2012, a copy of an itemized receipt orinvoice showing the name of the provider of the item or service, the date of service or dateof purchase, as applicable, and the amount will be required for reimbursement.

If payment has already been made, please make sure to include a copy (not originals) of theitemized receipt, invoice marked as paid with the payment method referenced such as a


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check number or credit card, or scanned check images (front and back) in place of an actualcancelled check.

If you are requesting funding for an annual membership, for example, for a pool or gym,please enter the yearly cost of the membership on the form. BAS will determine the eligiblefunding amount.

3. Check the box indicating that you have included this documentation.

4. Check the box indicating whether or not you have included a copy of a PAID receipt.

SECTION D: Please complete this section if you are requesting funding for respite.

1. Enter the name and address of the person providing respite. The address must be different thanthe address of the individual with autism.

2. Enter the costs and the dates of the respite.

3. All respite will be funded through reimbursement. The Reimbursement Form for Respite/Childcare will be sent to you. Receipts are not required for respite reimbursement.

SECTION E: VERIFICATION OF DIAGNOSIS

1. A licensed medical professional must complete the Verification of Diagnosis Form OR you mustattach a copy of a report confirming a diagnosis of autism or ASD. Please check the box telling uswhich form of verification you are using.

2. EITHER have a licensed medical professional complete the Verification of Diagnosis Form inSection F;OR

3. Attach a copy (DO NOT SEND ORIGINALS) of a report from a licensed neurologist, developmentalpediatrician, psychologist or psychiatrist confirming that the individual has an ASD diagnosis.

The date that the evaluation was completed is irrelevant. Please do not send an entireevaluation.


Cover sheet with demographic information of the individual with ASD on the letterheadof the practice or diagnosing agency/professional.

The page which indicates and/or states �“Axis 1 diagnosis�” of ASD or the �“diagnosticimpression�” which clearly states that the individual has a diagnosis of ASD. Additionally,if you wish, you may highlight or circle the diagnosis. Please note that a �“Rule Out�”diagnosis is NOT a diagnosis.

The signature page that includes the signature and license number of the licensedprofessional who determined the diagnosis or who can verify that the individual doeshave an ASD diagnosis (electronic signatures and copies of faxed documents areaccepted).

*Please note that educational testing and records are not an indication of diagnosis and will notbe considered proper documentation for this grant.


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SECTION F: CONFIRMATION OF ELIGIBILITYThe person completing the application must sign this page, and must be 18 years of age or older.

SECTION GPlease use the checklist to make sure you have included all the required items. Incomplete applicationswill not be considered for funding.

Please note that no documents will be returned, so make sure that you keep all originals. Pleasesend only copies.

MAILING INSTRUCTIONS:

Mail completed application and applicable supporting documentation to:Attn: F&I Mini GrantBureau of Autism ServicesPennsylvania Department of Public WelfarePO Box 2675Harrisburg, Pennsylvania 17105 2675

**Applications must be postmarked by April 15, 2012**

IMPORTANT NOTES:

Applications will only be accepted by mail. Faxed or emailed applications will not be considered.

BAS is not responsible for applications returned for insufficient postage, delayed or lost intransit. You may wish to consider sending your completed application via Certified Mail with areturn receipt to assure that our office has received your application.

We encourage you to make a copy of your application and all supporting documents prior tosubmission for your records.

Incomplete and illegible applications will not be considered for funding, so please be sure thatyour application is signed and complete with all necessary documentation attached.

Please remember that you are solely responsible for the completion of this application despiteany assistance that you may accept from third party sources (i.e. case managers, behaviorspecialists, etc.). However, you may wish to consider having a third party review yourapplication to assure that you have met all application requirements and have included allnecessary documentation.

Bureau of

For office use only:

App#

Last initial

CountyAPPLICATION FOR BUREAU OF AUTISM SERVICES2012 FAMILY AND INDIVIDUAL MINI GRANT

PLEASE REFER TO THE APPLICATION DIRECTIONS DOCUMENT AND READ ALL DIRECTIONS PRIOR TO COMPLETING APPLICATION.Complete and review ALL REQUIRED SECTIONS of this application before submitting.PLEASE PRINT LEGIBLY.

SECTION A This section should provide contact information for the person completing the form.

NAME OF PERSON COMPLETINGTHIS FORM**

First Name: Last Name:

**The person completing this form must be 18 years of age or older �– i.e. parent, guardian, or adult with autism applying for self.

RELATIONSHIP OF PERSONCOMPLETING THIS FORM TOTHE INDIVIDUAL WITH ASD

(CHECK ONE BOX)

I am filling out this form for myself

Parent/Step Parent

Sibling

Grandparent

Other ____________________________(please specify)

MAILING ADDRESS

STREET: APARTMENT #:

CITY:PA

ZIP CODE:

DAYTIME PHONE #( ) �—

AREA CODEEVENING PHONE #

( ) �—

AREA CODE

EMAIL ADDRESS (IF APPLICABLE)*Please supply an email addressthat you check on a regular basis

SECTION B This section should provide information about the individual with ASD.

NAME OF INDIVIDUAL WITH ASD

First Name: Last Name:

AGE & DATE OF BIRTH OFINDIVIDUAL WITH ASD(please write out month)

AGE (as of 4/15/2012): MONTH: DAY: YEAR:

COUNTY IN WHICH INDIVIDUALWITH ASD RESIDES

(e.g. Allegheny, Centre, Bucks)

FOR OFFICE USE ONLY:

DATE POSTMARKED: Eligible

Pending ___________

Ineligible

Database entrydate:______________

Entered by: ____________

Comments:

Autism Services P.O. Box 2675 Harrisburg, PA 17105 1.866.539.7689 FAX: 717.265.7761DPW [email protected] www.autisminpa.org www.dpw.state.pa.us

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FUNDING REQUEST CHART: REQUIRED

Copy this page if you need more space to list Supports, Activities, or Respite.TOTAL AMOUNT OF ALL SUPPORTS, ACTIVITIES, AND RESPITE MAY NOT EXCEED $500.

SECTION C Please complete this section for all support/activity requests, EXCEPT for Respite.

EligibleSupport/Activity

(e.g., Camp,Recreation, College

Course)

MAKE CHECK PAYABLE TO:Name of Organization

Providing theSupport/Activity

Cost ofSupport/Activity

Date(s) ofSupport/Activity

(must occurbetween

3/1/12 and8/31/12)

I have includeddocumentationshowing costfor support/

activity

I haveincluded acopy of aPAIDreceipt(IndicateYes or No)

FOROFFICE

USE ONLY

EXAMPLE:Summer Camp XYZ Camp $495 6/7/12 �–

6/11/12YES YES

NO1.

YESYESNO

FNFR PRR NPR

2.

YESYESNO

FNFR PRR NPR

3.

YESYESNO

FNFR PRR NPR

4.

YESYESNO

FNFR PRR NPR

SECTION D If you are requesting funding for RESPITE, please complete this section.

RESPITE REIMBURSEMENT:Provide the name & address of the person providing

respite. This addressmust be different than the addressof the individual with autism.

Cost ofRespite

Date(s) ofRespite(must occur

between 3/1/12and 8/31/12)

Receipts are not required forrespite reimbursement

FOROFFICE

USE ONLY

Please send me therequired reimbursementform for Respite/Child care

FNFR PRR NPR

FOR OFFICE USE ONLY

Total amount of all funding requested


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SECTION E VERIFICATION OF DIAGNOSIS

Please check only one box:A licensed medical professional has completed the Verification of Diagnosis Form below

I have a attached a copy of a report confirming a diagnosis of autism or ASD

Verification of Diagnosis Form

Please have a licensed medical professional (family physician, pediatrician, developmental pediatrician,neurologist; or licensed psychologist, licensed school psychologist, or licensed psychiatrist) fill out thefollowing form:

I attest that has a medical diagnosisof an autism spectrum disorder, ASD.

Medical Professional�’s Name (print)

Practice Address:

Provider #

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Medical Professional�’s Signature

SUBMIT THE ABOVE FORM OR:

Attach a copy (DO NOT SEND ORIGINALS) of a report from a licensed neurologist, developmentalpediatrician, psychologist or psychiatrist confirming that the individual has an ASD diagnosis.

The date that the evaluation was completed is irrelevant. Please do not send an entire evaluation.


Cover sheet with demographic information of the individual with ASD on the letterhead of thepractice or diagnosing agency/professional.

The page which indicates and/or states �“Axis 1 diagnosis�” of ASD or the �“diagnostic impression�”which clearly states that the individual has a diagnosis of ASD. Additionally, if you wish, you mayhighlight or circle the diagnosis. Please note that a �“Rule Out�” diagnosis is NOT a diagnosis.

The signature page that includes the signature and license number of the licensed professionalwho determined the diagnosis or who can verify that the individual does have an ASD diagnosis(electronic signatures and copies of faxed documents are accepted).

*Please note that educational testing and records are not an indication of diagnosis and will not beconsidered proper documentation for this grant.


SECTION F CONFIRMATION OF ELIGIBILITY*

*The person completing the application should sign this page. The person completing this form must be 18 years ofage or older �– i.e. parent, guardian, or adult with autism applying for self.

I agree and confirm that:

o I am a resident of Pennsylvania.o I am an adult with ASD or I am an adult (over the age of 18) and I have a family member with ASD.o The applicant and/or the individual with ASD does not currently receive, and has not received within

the past 12 months, any other family support services, including waiver funded services, FamilyDriven Support Services, services funded under Individual Support Plans, county based funds fromMH/DS or other similar services or funding.

o I agree to waive, release and forever discharge the Pennsylvania Department of Public Welfare,Tuscarora Intermediate Unit 11 (funding agent), their agents, representatives and employees fromany and all claims for damages to persons or property which may occur or be sustained during thecourse of, or arising out of, or in connection with this application or participation in the Bureau ofAutism Services Family and Individual Mini Grants program.

o I certify that all the information given above is true and correct and understand that if I am foundeligible, my grant may be terminated if I have made any material false or incomplete statements inthis application, either about myself or on behalf of the recipient. I authorize verification of theinformation provided in this application. This permission will survive the expiration of my granteligibility.

Signature of Person Completing this Application Date

DP 1034 2/12

SECTION G CHECKLIST

CHECKLIST

Please check that you have included the following REQUIRED items:

The completed and signed application Documentation stating the cost of the requested service and/or activity Verification of medical diagnosis (form filled out by a licensed medical professional or attachedcopy of required report items)

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED FOR FUNDING

bureau of autism services and mini rgrant application packet€¦ · bureau of autism services 2012...

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