APPLICATION FOR CAMP SCHOLARSHIP FUNDS
Description and Purpose
Camp Two Can scholarship funds are available to assist children ages 5-22* (age acceptance depends on location, some locations only go to age 18) to attend Camp Two Can. Scholarships are offered to ensure that individuals who would otherwise find it a financial hardship to attend Camp Two Can are able to participate and learn from the experience. All scholarship recipients are responsible for their food and ground transportation expenses. Scholarship preference will be given to applicants who have not received a scholarship award in the past three years. Incomplete applications will not be considered. Please note the deadline and submission dates and any additional requirements if any.
CONFIDENTIAL DATA – MUST BE COMPLETED IN FULL. PLEASE PRINT CLEARLY
Please check which camp location are requesting financial support for from the drop down menu:
SECTION I
Constituent Name: Date of Birth:
Parent Name:
Address:
City: State: Zip:
Phone: Email:
Coordinator’s Name:
School: School Phone: County:
Teacher’s Name:
Have you been granted financial aid from any PALS program before? Yes No If Yes, when and for what program?
SECTION II
Family Adjusted Gross Income (AGI)(as reported to IRS*)
less than $20,000 $20,000-$29,000 $30,000-$39,000 $40,000-$49,000 $50,000-$59,000 $60,000-$69,000 $70,000-$79,000 $80,000-$89,000 More than $90,000
How many people does this income support? ages of other siblings
Occupation- Father Currently Employed?Yes No
Occupation – Mother Currently employed?Yes No
SECTION III
Do you receive free or reduced lunch? Yes No If yes, please attach approval letter
Please list any types of State or Federal Aid received:
*Please note we may request a W-2
SECTION IV
1. What other programs will the child be attending during the summer:
2. Will siblings be attending camp or other summer programs: Yes No If yes, please specify.
3. We would like to know more about your child's desire to attend. Please write a brief paragraph below, and please include the following:
a. Why your child wants to attend camp
b. How you believe this experience will benefit your child
c. What alternative resources you've turned to before requesting financial aid from PALS
4. Explain why you are requesting Financial Aid. Please include special circumstances, such as unemployment, unreimbursed medical expense and other factors that will help us make a fair decision.
SECTION V
a. Total camp cost (if this is a weekly camp include the total x # weeks) $
b. Less deposit of - $
c. Less additional amount family can pay - $
d. Total of b and c $
e. Amount requested – subtract d from a $
FINANCIAL AID APPLICATION CHECKLIST:
ü Filled out Notarized Camp Two Can Application
ü Included deposit PER session registering for
ü Completely filled out Financial Aid Application
ü Included explanation on separate paper
All applications must be received by May 23, 2016. The financial aid committee will review
applications and make decisions by mid-May. We will notify you by e-mail (or letter) of the amount that you were awarded. The balance, your portion, if any, will be due according to the application. If you cannot pay your balance, your deposit will be refunded to you.
By submitting this Application, the undersigned Applicant (i) represents that the information and documents provided herein or attached hereto are true, correct and complete, (ii) authorizes PALS to verify the accuracy of all information and documents provided herein or attached, and authorizes and directs all third parties to provide PALS with any and all information regarding the information provided herein, (iii) acknowledges that the submission of this Application does not guarantee that Applicant will receive any assistance from PALS, (iv) represents that the Applicant has not already received or does not anticipate receiving any scholarships or other forms of financial assistance not otherwise described in this Application, (v) represents that Applicant is not related to any of PALS’s officers, directors or members of the Scholarship Committee, (vi) will use all awarded financial assistance for the intended purposes and will supply PALS with documentation of such use in the form requested by PALS, (viii) understands that the Applicant is responsible for determining whether any financial assistance provided by PALS is subject to federal, state, or local income tax, and (ix) understands and agrees that in the event Applicant’s representations herein, or documents attached hereto, are inaccurate, or Applicant intentionally submits false, incomplete or misleading information or documentation, Applicant immediately will return all funds provided and Application may be subject to criminal prosecution. The undersigned further acknowledges his or her understanding that any award and continuation of financial assistance from PALS shall be conditioned upon, in addition to the other factors described in the Scholarship Guidelines, as determined by PALS within its absolute discretion.
Your signature on this agreement form confirms that you have read the PALS Scholarship requirements and, if selected, commit to fully participate in the program provided under the granted scholarship.
Signature of Applicant Signature of Parent (if under age 18)
Date: Date:
Providing Autism Links & Support, Inc. is a public charity open to all applicants, and it does not discriminate based upon any criteria prohibited by law. Applications and inquiries should be sent to PALS, P. O. Box 781458, Orlando, FL 32878-1458.
For Committee Use Only
Date reviewed:______
Approval:______
Check #:______
Signature of Committee Member:______
Date:______
For office use only:
Date recvd ______Program #______Prog code ______
CR# ______Date______$______chk# ______name______
Submit application form and other requirements by email to
or mail to
PALS. PO Box 781458. Orlando, FL 32878-1458 or fax 407.823.6012.
The decision to make scholarship fund distributions is made by the scholarship committee, upon which no director or officer of PALS may sit (the “Committee”). The award of scholarship funds shall be based on (i) the nature of the particular program or course the applicant seeks to attend, (ii) the applicant’s need for financial assistance to attend the particular program or course, and (iii) the identity of the applicant, with preference given to individuals with autism, family members of children with autism, professionals working with children with autism or in related fields, and students studying in fields related to children with autism. Consistent with Revenue Ruling 56-304, 1956-2 C.B. 306, PALS shall maintain an individual case history of every Application received (whether accepted or declined), and shall maintain records evidencing the applicant’s financial need and use of the scholarship funds (if awarded). In order to avoid any appearance of self-dealing, grants shall not be made to any officer or director of PALS, or any member of the Committee, or their respective, immediate family members. PALS shall not discriminate in favor of or against any eligible individual on any basis, including race, religion, sex, national origin or place of employment.
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