Date

Child(ren)’s Name:

Parent’s/ Guardian’s Name:

Parent’s/ Guardian's Email Address

Parent’s/ Guardian's Telephone Number

Parent’s/ Guardian's Address/es

Type of Application

Boarding Daycare

My child attends/ wishes to attend Pathways Autism Centre of Excellence (PACE) on a

Full Time Basis Part Time Basis

Number of days per week

Period for which assistance is required
(Note that the application is required to be renewed on a termly basis, subject to availability)

Have you applied for financial assistance from us before?

Yes No

How much funding was provided?

Fill out the corresponding sections that best describe your situation:

Are you employed? Yes/ No

Yes No

Name of Employer/ Business

Amount of monthly income from employment/ business

Is your spouse/ partner / other family or household member employed?

Yes No

Do you or your spouse/ partner/ other family or household member earn income from any other source?

Yes No

Total (combined if applicable) amount of monthly income from employment/ business

Total cash/ savings and investments

Approximate total of monthly expenses (food, transport, rent, electricity, water, medical expenses etc)

Number of family members at home

In the space below, please describe any other reasons or circumstances (past, present, or future) that you feel increase your qualification and/or need for financial assistance. (e.g., family circumstances, academic standing, ministry or other responsibilities; etc.)

Conditions Upon Acceptance

Parents must provide proof of payment of their contributiuon in the stipulated amount to Pathways Autism Trust before this is matched with the necessary contribution in the form of financial assistance from the donor.
Proof of income and residence, and copy of National ID/ passport/ drivers’ license is required from the parent or guardian responsible for the Application and the family’s contribution..

I hereby confirm that the information provided above is true and accurate to the best of my knowledge.

APPLICATION FOR FINANCIAL ASSISTANCE

Conditions Upon Acceptance

Legal Stuff

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