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Autism Recovery System Scholarship Application
Name
*
First
Last
Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Child's Age
*
Child's Diagnosis
*
When was your child diagnosed?
*
Month
Day
Year
Have you worked with a biomedical doctor?
*
Yes
No
Are you currently working with a biomedical doctor?
*
Yes
No
Is your child on a special diet?
*
Yes
No
Do you have Internet access (this is a requirement)?
*
Yes
No
If chosen for a scholarship would you be willing to share testimonial in future if you find the program helpful to your family?
*
Yes
No
In approx. 1000 words: How would this scholarship benefit your family?
*
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