Autism Speaks Swimming Scholarship Program 2014 Autism Speaks Family Services

Report Fields Name of Organization* Name of Organization Character Limit: 250

Please fill in all fields marked with *.

Organization Web Site Please type in the link for your organization's web site in the space below, if applicable. Character Limit: 75

Name of Program* Please type the name of the swimming program that you are applying on behalf of. Character Limit: 100

Name of Program* How long has this program been in existence? Choices This program will be established in the near future This program has been established in the last year This program was established 1-3 years ago This program has been in existence for more than 3 years

Population Served* What population of clients does the organization serve? Include all that apply (e.g. autism, Asperger's disorder, other special needs, typical individuals).

Funding Schedule* Are you applying for a one-time Scholarship Fund or multiple quarters? Choices: One Quarter Two Quarters Three Quarters Four Quarters Character Limit: 150

Location: City* Character Limit: 50

Location: State* Character Limit: 50

Choices AL - ALABAMA AK - ALASKA AZ - ARIZONA AR - ARKANSAS CA - CALIFORNIA CO - COLORADO

CT - CONNECTICUT DE - DELAWARE DC - DISTRICT OF COLUMBIA FL - FLORIDA GA - GEORGIA HI - HAWAII ID - IDAHO IL - ILLINOIS IN - INDIANA IA - IOWA KS - KANSAS KY - KENTUCKY LA - LOUISIANA ME - MAINE MD - MARYLAND MA - MASSACHUSETTS MI - MICHIGAN MN - MINNESOTA MS - MISSISSIPPI MO - MISSOURI MT - MONTANA NE - NEBRASKA NV - NEVADA NH - NEW HAMPSHIRE NJ - NEW JERSEY NM - NEW MEXICO NY - NEW YORK NC - NORTH CAROLINA ND - NORTH DAKOTA OH - OHIO OK - OKLAHOMA OR - OREGON PA - PENNSYLVANIA RI - RHODE ISLAND SC - SOUTH CAROLINA SD - SOUTH DAKOTA TN - TENNESSEE TX - TEXAS UT - UTAH VT - VERMONT VA - VIRGINIA WA - WASHINGTON WV - WEST VIRGINIA WI - WISCONSIN WY - WYOMING Other

PROGRAM DESIGN

Program Design* Describe the design of the swimming program. Include how the swim lessons are tailored to individuals with autism (minimum of 2 paragraphs). Character Limit: 3000

Water Safety* How do the lessons address water safety other than learning how to swim (e.g. when it is appropriate to go in water or not, how to behave near water, sensory issues, fear of water)? Character Limit: 3000

Involvement of Parent/Caregiver* Is the parent/caregiver expected to be involved in the lessons? If so, how? (e.g. Will parent be in the pool with the child? Will the parent be expected to do any preparation or follow-through at home?) Character Limit: 1000

Facilities* Describe the pool facilities to be used, including size and depth of pool, indoor/outdoor, locker room/bathroom set-up (i.e. where would a mother take her 15-year-old son to change?), and other associated facilities or amenities. Character Limit: 1000

Equipment* Describe any specialized equipment or tools that will be used to support the swim lessons (e.g. safety equipment, sensory supports; behavior or learning supports; social stories; flotation devices; modified swimwear, goggles, or swim caps; etc.) Character Limit: 1000

Swim Session* What is the length of one swim session? Character Limit: 50

Frequency of Sessions* On average, how many sessions will one swimmer with autism take per week? Choices 1 2 3 4 5 6 7

Duration of Sessions * How many weeks will one swimmer participate in swim lessons? Character Limit: 5

Type of lessons* Are the sessions individual or group lessons? Choices Individual Group

Supervision* What is the program's swimmer/instructor ratio. (e.g. 2:1 = two swimmers to one instructor, 1:2 = two instructors to one swimmer) Character Limit: 10

Lifeguards* How many lifeguards are on duty during lessons?

Character Limit: 5

Instructors* Describe the qualifications and certifications of swimming instructors (e.g. American Red Cross Adult and Child First Aid, CPR & AED, American Red Cross Water Safety Instructor certification, # of years of experience, occupational therapist, behavioral therapist, special educator, etc.). Character Limit: 1500

Supervisory Staff* Describe the qualifications and certifications of supervisory staff, if applicable (e.g. American Red Cross Adult and Child First Aid, CPR & AED, American Red Cross Water Safety Instructor certification, # of years of experience, occupational therapist, behavioral therapist, special educator, etc.). Character Limit: 1500

Staff Training* Describe the instructor/facility staff training in Autism Spectrum Disorders. Character Limit: 1500

Safety* Describe the safety procedures the program uses with swimmers with autism (e.g. ??) Character Limit: 500

Insurance* Are you fully insured against possible injuries and damages incurred by participants? Choices Yes No Other – describe below Character Limit: 200

Inclusion Criteria* What is the program's inclusion criteria for swimmers (e.g. age, gender, developmental diagnosis, medical diagnosis)? Character Limit: 300

Exclusion Criteria* What is the program's exclusion criteria for swimmers (e.g. age, gender, developmental diagnosis, medical diagnosis)? Character Limit: 300

Total Number of Swimmers* What is the total number of swimmers that are expected to participate in swimming lessons in your program in 2014? Character Limit: 5

Swimmers with autism* What percentage of swimmers are expected to be individuals with autism? Character Limit: 3

Number of Swimmers in the Pool* How many swimmers will be in the pool at one time? Character Limit: 10

Other Pool Use*

During swim lessons, is the pool in use by other groups or individuals? Will anyone else be in the pool during lessons? If so, what precautions will be taken to ensure the safety and comfort of all involved? Character Limit: 1000

SCHOLARSHIP/ FINANCIAL INFORMATION

Cost* What is the cost of one session per swimmer? Character Limit: 6

Describe any additional charges.* Character Limit: 800

Scholarship Extent* How many sessions would the scholarship cover per person? Character Limit: 5

Scholarship Recipients* How many swimmers would be served with this scholarship? Character Limit: 5

Other Funding* List all swimmer scholarship programs and other sources of financial aid in 2014. Character Limit: 800

Financial Policy* Describe the program's Financial Aid policy. Include the criteria used to award scholarships. Character Limit: 1000

Matching Funds* Does the program have potential matching funds available for the Autism Speaks Swimming Scholarship Program? Choices Yes No

Other Scholarships* Are other organizations being solicited for 2014 scholarships for swimmers with autism? If so, list organizations. Character Limit: 1000

Qualified Swimmers* If this program is selected, describe the process the program will use to select scholarship swimmers for the Autism Speaks Swimming Scholarship Program. Character Limit: 2500

COMMUNITY

Announcement* If this program is selected, describe how the swimming scholarships will be announced to the community (e.g. website, newsletters, special promotions, other). Character Limit: 800

Experience* If this program is selected, describe how the scholarship swimmer’s experience will be evaluated. Character Limit: 1000

Awareness*

How did you learn about the Autism Speaks Swimming Scholarship Program? Choices Autism Speaks website eSpeaks Local publicity Family Service Provider Other-describe below

Other* Is there other program information you would like to share with us? Character Limit: 800