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Gender of Child
Does the Child have Health Insurance?
Are You Employed?
Type of Insurance (check all that apply)
Sources of Income (pick all that appy)

Demographic Information

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AUsome Gavin & Friends Foundation is committed to serving all ALL children being diagnosed with Autism in our service area regardless of their race or ethnicity. The following information is collected solely for demographic purposes to help us better serve autism in our community and is NEVER used in the decision to provide aid.

Which of the following best describes you? (please select one)
May we share your story to help us promote our organization for future purposes? Your answer WILL NOT be used in our decision to provid financial assistance
How did you hear about us?

If you were referred by your treatment provider's office (financial aid manager, case manager, etc.) please provide contact information for that person below:

PLEASE UPLOAD THE RESULT OF THE DIAGNOSIS

Upload File

GRANT APPLICATION WILL NOT BE REVIEWED WITHOUT A SIGNATURE

I certify that the information I have provided in this application is true and accurate. I give permission for doctors and staff to provide information about my child's condition and treatment to AUsome Gavin & Friends Foundation.

Thanks for applying!
We’ll get back to you soon.

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