ESDM Scholarship Application

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.

1. Child's date of birth:

on May 1 or Oct 1 (at the END of Open Enrollment period in which applying).

(If finalist status is accepted, documentation of child's diagnosis of autism must be provided at that time)

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: *

(To qualify for an autism scholarship, total CURRENT annual gross income of all members of the family household cannot exceed $250,000.00.)

(If finalist status is accepted, Applicant MUST submit prior year federal income tax return(s) for all members of family household.)

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

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. *

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.

Application – Autism Scholarship Parent Coaching in the Early Start Denver Model (P-ESDM)