Please provide us with the following information so we can review your service request.

All information you enter here is kept strictly confidential and will only be reviewed by the board of Autism Radio.

Some pre-qualifying information to be aware of before filling out the application:

• A double income family's gross income shouldn't exceed $70,000 per year. 
• A single income family's gross income shouldn't exceed  $40,000 per year.
• A 2-year waiting period is imposed before re-applying for additional services given.

NOTE: We also require a letter from a doctor for your child's diagnosis and a copy of last year's FULL tax return.

You will be asked to attach them to the end of this form.

If we require any additional information, we will contact you.

Filling out this form does not guarantee services request will be fulfilled.

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