First Name

Last Name

Organization/Title

I am a: I am a: parent person with autism grandparent / other relative friend professional (e.g., teacher, therapist, case manager)

Work Phone

Cell Phone

Email Address

Street Address

City

State

Zip

County

Race of Grant Recipient Race of Grant Recipient American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other

How May We Contact You? How May We Contact You? Work Phone Cell Phone Email

Project Title

Will this grant affect one person with autism or a number of individuals with autism? Will this grant affect one person with autism or a number of individuals with autism? One More than one

Number of individuals with autism that will be affected by this grant?

What is the name of that person?

Tell us about the person/people who will be helped by this project

How old are they? If multiple people just tell us the age of the youngest and the oldest person.

How do you think this individual(s) will be helped by your project?

If yes, describe what they recommended.

How long will your project/activity be implemented?

When do you want your project to start?

Will your project continue after the grant funding is utilized?

How will you use the money from the grant?

Amount Requested (Maximum of $500.00)

What does the total project cost?

If the total cost of your project is more than the amount you are requesting, how will you fund the rest of your project?

If your project is not awarded the CIAA grant or only part of the grant money is awarded, will you still be able to implement the project? If your project is not awarded the CIAA grant or only part of the grant money is awarded, will you still be able to implement the project? Yes No Maybe

If yes, how will the project change if you do not get the full CIAA grant amount?

Are you a professional? Are you a professional? Yes No

What is the makeup of your classroom/caseload/clinic that is benefiting from this grant?

Describe some of the research that supports your request.

Have you consulted with another professional (e.g., OT, BCBA, SLP, etc) for your project? Have you consulted with another professional (e.g., OT, BCBA, SLP, etc) for your project? Yes No

What were their recommendations?

Have you attempted to fund this project in other ways? Have you attempted to fund this project in other ways? Yes No

How much are these groups willing to contribute to your project?

By submitting this application, I agree to the terms and declarations below: By submitting this application, I agree to the terms and declarations below: I Agree