Special Interest Fund Scholarship

Special Interest Fund Scholarship is sponsored by KNOWAutism Foundation. The Special Interest Fund was established to help individuals with autism in the Greater Houston Area access adaptive and inclusive programs and services that do not fall under the umbrella of traditional autism treatments or interventions.

Clone of 2025 KNOWAutism Foundation Special Interest Program Assistance Application Special Interest Scholarship Application The KNOWAutism Foundation Special Interest Fund was established to help children with autism access adaptive and inclusive programs and services that do not fall under the umbrella of traditional autism treatments or interventions.

If you are seeking financial assistance for traditional therapeutic intervention services such as speech therapy, occupational therapy, ABA therapy, specialized private schools or education, please complete the Tuition and Therapy Application. Please Note: This fund does not cover experimental procedures, day care, after school care HBOT, supplements, acupuncture, homeopathy, or other alternative treatments.

Do you reside in the Greater Houston Area? Defined as residing in one of the following 9 counties: Austin, Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery and Waller. * Is the scholarship applicant a U.S. Citizen?

Please note: we are only accepting applications from U.S. Citizens at this time. * 2 digit month, 2 digit day, 4 digit year Date Scholarship Applicant's Full Name: * Scholarship Applicant's Date of Birth: * Scholarship Applicant's Gender/Sex: * Date of Autism Spectrum Disorder Diagnosis (Diagnostic assessment required with this application): * 2 digit month, 2 digit day, 4 digit year Is the scholarship applicant verbal or non verbal?

* Has the scholarship applicant received any therapeutic services prior to today including speech therapy, occupational therapy or ABA therapy? If yes, please list each type of therapy, how long the scholarship applicant received services for, the name of the provider, and any notes about each therapy/intervention. Please indicate if the services have been offered by the school district or a therapy clinic.

The more information, the better. If no, enter N/A. * Parent/Guardian #1's Name (person completing this application): * Parent/Guardian #1 Address: * Parent/Guardian #1 email: * Parent/Guardian #1 Cell Phone Number: * Please enter a valid phone number.

Format: (000) 000-0000.

Parent/Guardian #1's marital status: * Married to parent/guardian #2 Living Separately, but legally married to parent/guardian #2 Married to someone other than parent/guardian #2 Parent/Guardian #2's Name: * Parent/Guardian #2's marital status: * Married to parent/guardian #1 Living separately, but legally married to parent/guardian #1 Married to someone other than parent/guardian #1 Parent/Guardian #2 Address (if different from Parent/Guardian #1): Parent/Guardian #2 email: Parent/Guardian #2 Phone Number: Please enter a valid phone number.

Format: (000) 000-0000. Name of the provider or facility you are requesting services from (and that we will pay directly, if awarded a scholarship)? * Provider/Facility Address * Please enter a valid phone number.

Format: (000) 000-0000. Facility/Provider Contact Name: * Facility/Provider Contact email: * Has the scholarship applicant received services from this provider before? * Please describe the program/service you are requesting financial assistance to cover and how it will be helpful for the scholarship applicant.

* Total cost of program/services being requested and designate the time frame for the services (per week, per visit, per month, etc.) For example, I want my son Jack to receive swim lessons for two months. It costs $200 a month for 4 swim lessons. The amount you would enter below would be $400 = $200/month x 2 months.

* How often would you like for the scholarship applicant to receive services or for how long? * Grant amount requesting: * Gross Annual Income for parent/guardian 1 (Household): * Parent/Guardian 1's number of dependents (defined as a person (usually a child) you claim on your tax return as a legal dependent under the age of 19, unless attending college and then the child can be up to the age of 26.

Please include any legal dependents you have guardianship for). DO NOT INCLUDE yourself or spouse. A copy of parent 1's tax return is required with this application): * Do any of parent/guardian 1's other legal dependents have special needs?

If so, please list their name(s), age(s), and diagnoses. * Gross Annual Income for parent/guardian 2 (Household): * Parent/Guardian 2's number of dependents (defined as a person (usually a child) claimed on their tax return as a legal dependent under the age of 19, unless attending college and then the child can be up to the age of 26. Please include any legal dependents you have guardianship for).

DO NOT INCLUDE yourself or spouse. A copy of parent 2's tax return is required with this application unless they do not have legal custody of the scholarship applicant. If parent/guardian #1 and parent/guardian #2 are married, please enter N/A.

* Do any of parent/guardian 2's other legal dependents have special needs? If so, please list their name(s), age(s), and diagnoses. If parent/guardian #1 and parent/guardian #2 are married, please enter N/A.

* If parents/guardians of the scholarship applicant are not legally married, who has court ordered decision making authority for educational, medical and psychiatric treatment for the scholarship applicant?

If parent/guardian #1 and parent/guardian #2 are legally married to one and other, type N/A * If the parents/guardians are not legally married, does the other parent/guardian provide any type of financial assistance for the scholarship applicant? If the other parent/guardian is court ordered to provide child support and/or cover out of pocket medical expenses but does not currently pay, please include relevant information.

If not applicable, please type N/A. * Does the scholarship applicant you are applying on behalf of currently receive SSI? * Has the scholarship applicant you are applying on behalf of received SSI in the past?

If they have received SSI in the past but are not currently receiving this benefit, please explain. If the dependent has been approved for SSI but has not yet received payments, please include that information. If not applicable, please enter N/A.

* Is parent/guardian 1 legally disabled and receiving disability benefits? * Yes, I am legally disabled and am receiving disability benefits. No, I am not legally disabled.

Yes, I am legally disabled, but I am not receiving any benefits. Yes, I am legally disabled and have received disability benefits in the past, but am not currently. Is parent/guardian 2 legally disabled and receiving disability benefits?

* Yes, parent 2 is legally disabled and is receiving disability benefits. No, parent 2 is not legally disabled. Yes, parent 2 is legally disabled, but is not receiving any benefits.

Yes, parent 2 is legally disabled, has received disability benefits in the past, but is not currently receiving any disability benefits. I do not know if parent 2 is receiving disability benefits. What other types of financial assistance does parent/guardian 1 receive?

Please include all financial assistance from the government, family, friends, place of worship, significant others, etc. (Please note: Receiving assistance from additional sources does not necessarily go against the scholarship applicant. The grants committee is looking for a wholistic view of your financial situation.

We applaud parents/guardians who are resourceful and are doing everything they can to provide for the scholarship applicant.) : * What is parent/guardian #1's current living situation? * Own Home Rent Home/Apartment/Residence Live with family Live with boyfriend/girlfriend or other person you are not legally married to (does not include family) Live in government subsidized housing Other If other, please explain.

Is the scholarship applicant currently covered by private medical insurance (not including Medicaid)? * If yes, what type of medical insurance plan is the scholarship applicant covered under (not including Medicaid)? This type of insurance is usually provided by a parent's employer or the Healthcare Marketplace/Obamacare.

* PPO through parent/guardian's employer HMO through parent/guardian's employer Name of insurance company (not including Medicaid; a copy of the front and back of the insurance card is required with this application): In network out of pocket max: Out of network out of pocket max: Is the scholarship applicant currently enrolled with Medicaid in Texas? * If yes, what plan is the scholarship applicant currently enrolled in?

* Texas STAR (typically low income) STAR Kids (Children and adults 20 years and younger who have disabilities) STAR + PLUS (Adults with disabilities or are 65 or older) Traditional Medicaid (available only if not enrolled STAR, STAR+PLUS, STAR Kids, or STAR Health)\ Are any of the services you are requesting financial assistance with covered by medical insurance (not Medicaid)?

* If yes, is the provider you are seeking assistance with in network? * If these services are covered by medical insurance (not Medicaid), what is your expected out of pocket for the services you are requesting assistance for? If not applicable, please enter N/A.

* Describe your particular financial situation and why you are seeking financial assistance. Detailed responses are encouraged. * Have you applied for financial aid, scholarships, grants, or other type of financial assistance from any other organizations or agencies to cover any part of the requested services?

* If yes, please include the names of the entities from which you have applied, the date, and the amount of assistance requested. If not applicable, please enter N/A. * If you have been awarded financial assistance from another entity to cover any part of this request, please list the name(s), amount(s), and time period(s).

If not applicable, please enter N/A. * Has the dependent previously received a grant from the KNOWAutism Foundation? * If yes, list year(s) and amount(s) awarded: How did you hear about our grants program?

Please be specific * By signing this form, you certify that all answers provided are true and complete to the best of your knowledge. I understand that incomplete applications will not be considered. I understand knowingly providing false information will disqualify my family from consideration for all current and future grants offered by the KNOWAutism Foundation.

I grant permission for the KNOWAutism Foundation to contact individuals and entities listed on this application for verification and to collect additional information, if needed. I understand a maximum of one application per scholarship applicant may be submitted every twelve (12) months from the date of the last application. I understand I may withdraw my application, at any time, in writing to info@know-autism.

org.

2 digit month, 2 digit day, 4 digit year Browse Files Drag and drop files here Detailed Invoice from Provider for services requested for the scholarship applicant: * Browse Files Drag and drop files here Parent/Guardian #1's 2022 Tax Return (social security numbers may be redacted): * Browse Files Drag and drop files here Parent/Guardian #2's 2022 Tax Return (social security numbers may be redacted): Browse Files Drag and drop files here Medical Insurance Card for scholarship applicant (front): Browse Files Drag and drop files here Medical Insurance Card for scholarship applicant (back): Browse Files Drag and drop files here Medicaid Card for scholarship applicant (front): Browse Files Drag and drop files here Certified Divorce Decree/Custodial Agreement: Browse Files Drag and drop files here Browse Files Drag and drop files here Browse Files Drag and drop files here Other (anything additional you'd like considered): * Browse Files Drag and drop files here