ADONIS AUTISM CENTER OF SOUTHWEST FLORIDA 

RICHARD BASHAW GRANT

You are eligible if …………………

___ you are a resident of Lee, Charlotte, Collier, Hendry or Glades counties (Florida)

___ you are 16 years of age or older and diagnosed with autism.

___ you are applying for program that is not currently covered under any government
       assistance programs. (use of the word program can mean any activity, class, respite care, etc..)

____you have not received grant money from Adonis in previous year (must wait one full year before re-applying)

If the above criteria is true, you are eligible to apply for any type of program that is of special interest to you.  Grant money will be awarded directly to the organization, teacher, etc….in which you are applying.  
This grant will be for the awarded amount of money and will not be for continuing  program over an extended period of time.

NOTE:  THERE IS NO DEADLINE FOR APPLICATIONS TO BE SUBMITTED.  ADONIS WILL ACCEPT APPLICATIONS THROUGHOUT THE YEAR (JAN-DEC).  

		  Please mail the completed packet to:

		Adonis Autism Center of S.W. Florida
		        Richard Bashaw Grant
			    P.O. Box 2134
	    	      Fort Myers, Florida  33902

	GRANT APPLICATION PACKETS MUST INCLUDE:

___ The completed and signed application form.  
___ Two letters of recommendation.  One letter must be written by someone directly 
       involved in the program you are applying grant money for.  (i.e., teacher, 
       supervisor, mentor , etc….).  These letters must be from someone other than family
       members and address your strengths, skills and any other information that should be
       taken into consideration by the grant committee in its review process.   Letters
       must be current (within six months of the deadline), dated and signed.  

The grant(s) will be awarded within ten (10) days of receiving completed applications.

Questions and additional information can be directed to Beth Bashaw Cameron at 239-671-5387
THE ADONIS AUTISM CENTER OF S.W. FLORIDA

RICHARD BASHAW GRANT
(Grants may be for any amount - a budgeted allowance of $5,000 (not to exceed) may be awarded  in this twelve (12) month period.
APPLICANT INFORMATION (Please type or neatly print all information).

Name______________________________________________________________

Address____________________________________________________________

E-mail address_________________________________Phone_________________

Date of birth________________School or day program________________________

Any assistance through any federal or state programs, such as med-waiver, etc….______

If yes, please list__________________________________________________________

Support Coordinator____________________________Tel. #______________________

Program paid in advance may still be open to this grant for consideration.  You will need completed application, along with receipt of payment and copy of cancelled check.  

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Program you are applying grant money for_______________________________

_______________________________________________________________________

Address of organization listed above__________________________________________

Tel. # of organization_________________ Contact person ________________________

Cost of  program you are applying for ~ $

Please briefly explain your interest, need and desire to be part of program you are applying grant money for ~

Please include any additional information that may be helpful to us in making our decision ~

LETTERS OF RECOMMENDATION
Please note:  Provide letter of recommendation from two (2) people, other than family members, who will address your strengths, skills, needs and desire, along with any additional information for the review committee to take into consideration during review of application.  One of these letters must be from someone directly involved with the program you are applying assistance from.  Letters should be current (within six months of the deadline), dated and signed.  

CERTIFICATION
I/We hereby affirm that the information on this form is true and complete to the best of my/our knowledge.  I/We are aware of the conditions under which this grant is awarded and promise to inform Adonis Autism Center of S.W. Florida of any change in circumstances.  In the event an award is provided, photographs of applicant may be used in publicity, newsletters and other Adonis Autism Center of S.W. Florida’s events.  Failure to sign does not mean you will not receive grant money.  

_______________________________________________________________________
Applicant Signature                               Date			Parent/Guardian Signature

		

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		     for office use only ~ applicant, please do not write below.

Packet includes:

•	Complete and signed application
•	Two letters of recommendation
•	Applicant’s information checked