Oklahoma Statewide Autism Conference FAMILY STIPEND APPLICATION

Oklahoma Statewide
Autism Conference
FAMILY STIPEND APPLICATION
WHO IS ELIGIBLE?
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Applicants must be an individual with autism or a parent, legal guardian or grandparent of individual with autism.
APPLICATION PROCESS
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Applicants must register and pay to attend the conference prior to submitting application form.
Applicants must complete both pages of the stipend application.
Applicants must complete all required paperwork by the University of Oklahoma Health Sciences Center for payment.
Applicants are responsible for making own transportation and lodging arrangements.
Applications will be accepted through October 31, 2014.
STIPEND PAYMENT PROCESS
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Recipients must attend one full day of the conference.
Stipend payments are processed through the University of Oklahoma Health Sciences Center and will be sent to
recipients after the conference.
Personal Information
Name
Relationship to Individual with Autism
Address
City / State / Zip
Phone
Alternate Phone
Email Address
I have read and meet the above listed eligibility terms. If I am unable to attend the conference, I will notify the Oklahoma
Autism Network by October 31, 2014, so that the stipend may be awarded to another recipient.
Signature
How to Apply
1.
Mail completed form to: Oklahoma Autism Network, College of Allied Health, University of Oklahoma Health Sciences
Center, 1200 North Stonewall Avenue, Room 1140, Oklahoma City, OK 73117
2.
Fax completed form to 405.271.2630
Oklahoma Statewide Autism Conference, November 14-15, 2014, Embassy Suites Norman – Hotel & Conference Center, Norman, Oklahoma
c/o Oklahoma Autism Network, Tolbert Center for Developmental Disabilities & Autism, University of Oklahoma Health Sciences Center
1200 North Stonewall Avenue, Oklahoma City, Oklahoma 73117
www.okautism.org • Toll-free 877.228.8476 • Local 405.271.7476 • Fax 405.271.2630 • Email: [email protected]
Enhancing Lives: Confidence • Competence • Capacity
Oklahoma Statewide
Autism Conference
Please explain why you would like to attend the 2-day conference:
Please explain what you hope to gain:
Please explain how you will share what you learn with your community:
Oklahoma Statewide Autism Conference, November 14-15, 2014, Embassy Suites Norman – Hotel & Conference Center, Norman, Oklahoma
c/o Oklahoma Autism Network, Tolbert Center for Developmental Disabilities & Autism, University of Oklahoma Health Sciences Center
1200 North Stonewall Avenue, Oklahoma City, Oklahoma 73117
www.okautism.org • Toll-free 877.228.8476 • Local 405.271.7476 • Fax 405.271.2630 • Email: [email protected]
Enhancing Lives: Confidence • Competence • Capacity
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