All information submitted to MCAF will be sent securely and shall remain confidential.
After completing the application, you will need to email supporting documents to MCAF. You will recieve instructions after the submitting the application.
Date of Birth
Date of Diagnosis
Age when diagnosed
Combined monthly household income?
Do you recieve state or federal assistance?
If yes, what is the monthly amount?
Do you have private health insurance for your child?
Is this through an employer?
If yes, who is the employer?
If yes, what is the name of the insurance carrier?
Do you have state paid insurance for your child?
Monthly debt payments?
Description of services for which you would like assistance for:
Do you currently have a service provider?
If so, please privide the name/address/phone number of provider:
What is your estimate of the cost of services?
BY TYPING YOUR FULL NAME IN THE FIELD BELOW, SELECTING 'YES' AND CLICKING ON SUBMIT, YOU ARE STATING THAT ALL INFORMATION ENTERED ON THIS APPLICATION IS TRUE, TO THE BEST OF YOUR KNOWLEDGE.
Applicants Full Name
Is all information entered true, to the best of your knowledge?
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Monroe County Autism Foundation 2668 S. Adams St. #10
Bloomington IN 47403