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Home
About Us
Our History & Mission
Evolution of Unicorn Children's Foundation
Meet the Staff
UCF Board Members
What We Do
Testimonials
Our Programs
Community Impact
Programs
Unicorn Connection Center
>
Unicorn Connection Hub: Virtual Class Schedule
Uniquely Gifted Boutique©
Unicorn Connection Center Visual Cookbook
Uniquely Gifted Boutique Etsy Store
Transition & Adulthood Programs
>
Unicorn Village Academy
Project SEARCH
Unicorn Connection - Job Club
Family Navigation Programs
>
Early Start Denver Model (ESDM) Autism Parent Coaching
Mindfulness Stress Reduction Program
Virtual Support Group for Parents of Special Needs
211 Special Needs Hotline
Unicorn Children's Foundation Clinics at NSU
Mobile Developmental Clinic
Respite Education & Support Tools (REST) Companion Training
Collective Impact Programs
>
Creating Compassionate Children
>
Our Story
Store
Testimonials
Resources
Get Caught Being Kind™
Videos
Take the Pledge
Evaluation Form
Special Needs Advisory Coalition (SNAC)
Junior Board Members
Special Percs©
E ME UNI THE UNICORN™️
Get Involved
Become a Partner
Become a Volunteer
I Am...
Join Our Mailing List
Events
8th Annual $100,000 Golf Challenge
Creative Workforce Solutions Conference
2020 Community Inclusion Awards
Event Calendar
Attend an Event
Press
UCF In the News
Photos
Press Releases
Videos
Blog
Supporters
Community Partners
Visionary Society and Order of the Unicorn
Youth in Service Ambassadors
Contact
Donate
Donate Now
Ways to Give
Thank You to our Donors!
Support our Programs
Application – Autism Scholarship Parent Coaching in the Early Start Denver Model (P-ESDM)
Website:
unicornchildrensfoundation.org/esdm
. Review Terms and Conditions and see Open Enrollment Dates on website. Complete and submit application by email to:
scholarship@eunicorn.org
. An application may be submitted at any time, and will be considered during the next scheduled Open Enrollment period. Any scholarship awarded, of up to approximately $3,400 per scholarship, will be applied directly to cover costs of 14 parent coaching sessions conducted by a Board Certified Behavior Analyst/ESDM Certified Therapist of Early Start Autism LLC at a facility in or near Jupiter, Florida. No scholarship sums will be paid to the scholarship recipient.
(Rev. 04-09-18)
TO QUALIFY:
Review additional qualifying requirements in Terms & Conditions on autism scholarship website.
a) Child
MUST
be 12-52 months of age at
END
of Open Enrollment period in which applying.
b) Child should either have a diagnosis or be awaiting an evaluation for diagnosis of autism.
c) Total current annual gross income of family household is limited to a maximum of $250,000.00.
d) Applicant
MUST
be child's Parent or Legal Guardian.
e) All 14 sessions must be attended with child and Applicant (with child) must attend a minimum of 12 sessions.
f) Applicant
MUST
accept status as a finalist or award recipient within 48 hours of notification or scholarship may be forfeited.
Application Number: (for Unicorn use only)
*
1. Child's date of birth:
*
Indicates required field
Month
*
Day:
*
Year:
*
Age in months now:
*
2. Child’s gender:
*
Male
Female
3. Child’s age in months:
*
on May 1 or Oct 1 (at the END of Open Enrollment period in which applying).
4. Does child have a sibling or parent with autism?
*
Yes
No
5. Does child have a sibling or parent with any other exceptionality or disability?
*
Yes
No
6. Does child have a diagnosis of autism?
*
Yes (if "Yes", skip to question 9)
No (if "No", continue with question 7)
(If finalist status is accepted, documentation of child's diagnosis of autism must be provided at that time)
7. If child does not have a diagnosis of autism, is child on a waiting list to be evaluated?
*
Yes
No
8. If child is on waiting list to be evaluated for autism, and child is between 16-30 months of age, please complete the M-CHAT at https://www.m-chat.org/mchat.php and indicate M-CHAT score here.
M-CHAT-Score:
*
9. How many hours of therapy is the child receiving each week?
*
0 hours
1-5 hours
6-10 hours
11-15 hours
16-20+ hours
10.
10a. Total people in family household: (Total must agree with number of adults & children entered.)
*
10b. How many adults:
*
10c. How many children:
*
11. Total CURRENT annual gross income of all members of the family household: $
*
(To qualify for an autism scholarship, total CURRENT annual gross income of all members of the family household cannot exceed $250,000.00.)
12. Total PRIOR YEAR annual gross income of all members of the family household: $
*
(If finalist status is accepted, Applicant MUST submit prior year federal income tax return(s) for all members of family household.)
13. Applicant agrees that all 14 sessions will be attended with child and Applicant MUST attend a minimum of 12 sessions.
*
Yes
No
14. Applicant agrees to provide own transportation to/from coaching sessions at a facility in or near Jupiter, Florida?
*
Yes
No
15. Upon final acceptance, Applicant is expected to pay a nominal fee (currently $140), a portion of the up to approximately $3,400 cost of this P-ESDM scholarship. After completing all 14 parent coaching sessions and the post-evaluation forms, some or all of the $140 fee paid by Applicant will be refunded. Will Applicant commit to paying the $140 fee online in one lump-sum payment within 48 hours of notification of award of a P-ESDM scholarship?
*
Yes
No
If answer is "No", please explain why:
*
16. Briefly state the reason you wish to participate in this Parent Coaching in the Early Start Denver Model autism scholarship program, and also furnish any additional comments you wish to be considered.
*
17. Have you ever applied for or been selected to receive a Unicorn ESDM autism scholarship?
*
Yes
No
If yes, indicate month and year? (mm/yyyy)
*
18. How did you learn of the Unicorn ESDM autism scholarship? (Check all that apply.)
*
Website
Email
Flyer
FAU CARD Little Owls
Physician
Facebook
Health Care Professional
Daycare
Friend
Other:
*
Applicant: (MUST be child's parent/legal guardian)
*
First
Last
Relationship to Child
*
Mother
Father
Legal Guardian
Applicant’s Day Time Phone Number
*
This number can receive text messages?
*
Yes
No
Secondary Phone Number
*
Email
*
Confirm Email
*
Home Address
*
Line 1
Line 2
City
State
Zip Code
Country
County (Example: Palm Beach, Martin, etc.)
*
Additional Contact:
Relationship to Child
*
Mother
Father
Grandparent
Caretaker
Other:
*
First Name
*
Last Name
*
Day Time Phone Number
*
Email
*
Confirm Email
*
Name of Child
*
First
Last
By submission of this autism scholarship application, I acknowledge that I have read, agree to, and accept the Terms and Conditions on the website for the P-ESDM autism scholarship program. I agree to the use of electronic communications in the handling and processing of this application. Within 48 hours of notification, I agree to respond by email to accept/decline finalist status; and if accepted (1) to furnish prior year income tax return(s); (2) to sign a Release; and (3) to provide additional documentation as required prior to the designated deadline. If awarded an autism scholarship, I agree within 48 hours to accept/decline the award and to pay the $140 fee online in one lump-sum payment (unless otherwise indicated in No.15 above).
I agree to notify Unicorn immediately of any changes in my personal contact information, including my email address, phone number(s), and mailing address.
Digital Signature of Applicant (Child's parent or Legal Guardian)
*
Date: Signed
*
Submit