We are committed to making this programme accessible. A limited number of bursary-funded places are available for families who may face financial barriers to participation. Please complete the form below:

Bursary Application

This application form is for children with autism whose families wish for them to benefit from an Applied Behavioural Analysis (ABA) programme. The Playhouse Foundation is offering bursaries to fully or partially fund Hampshire based families with young children. All our families are means-tested and are not to be currently receiving an ABA programme.

Please note that a diagnosis is not essential, as our trained consultants are able to assess the child prior to a completed diagnosis.

Early Intensive Behavioural intervention is an educational programme based on ABA for young children with autism. Parents of successful applicants will be expected to demonstrate commitment to the programme. They must make available one clean living room dedicated to the programme. They will be responsible for recruiting their own tutors and timetabling and fully participate at regular team meetings.

It is anticipated that parents will use the opportunity provided by the ABA programme, enabled with funding provided by The Playhouse Foundation, to proactively gather evidence to try to secure an Education, Health & Care Plan for their child by the end of the first year of the programme. The Trustees cannot guarantee any funding beyond the end of year one of the programme.

The Playhouse Foundation Trustees require parents applying for means tested bursaries to complete the application form and provide documentary proof of income, such as a P60 or self-employed tax return. The Trustees also ask for proof of savings and capital assets including details of monthly mortgage or rental payments. The Trustees assess eligibility based on household income but will make some adjustment to allow for other dependent children. In addition, parents are asked to submit any professional assessments that may have been carried out in relation to their child’s autism to enable the Trustee’s to assess needs. Parents are asked to declare that the information they are providing is both accurate and complete. If the information provided is subsequently discovered to be false or misleading, The Playhouse Foundation Trustees reserve the right to withdraw the means tested ABA bursary.

Having submitted the application form, one of the Trustees will be in contact to conduct an informal interview. In addition, families shortlisted may require a home visit by one of our consultants to assess the child’s needs in more detail.

Child's Information

Child's First Name:

Child's Last Name:

Child's Date of Birth:

Day

Month

Year

Does your child have a diagnosis of Autism Spectrum Disorder?

Yes

Date of diagnosis:

Day

Month

Year

Traits of autism (e.g. verbal / non-verbal):

Other medical conditions:

Parent/ guardian 1 contact details

First name 1:

Last name 1:

Email address 1:

Phone number 1:

Parent/ guardian 2 contact details

First name 2:

Last name 2:

Email address 2:

Phone number 2:

Employers name and contact information. If self employed, type of business:

Financial Information

Total gross (pre tax) earnings of both parents/ guardians:

Benefits income:

Pension income:

Maintenance income:

Other income:

Savings:

Other assets:

Mortgage or rent payment per month:

Loans/ overdraft payments per month:

Utilities payments per month:

Travel payments (private or public transport) per month:

Food payments per month:

Other commitments per month:

Select which documents you are submitting to verify your income:

P60 & P11D (if applicable)

Payslip

Reports and accounts

Copy of HMRC tax calculation issued under self assessment

Confirmation of schedule D self employment income from independent accountant

Other

Please upload proof of income

Please upload proof of outgoings

Details of professional assessments (please upload supporting documentation):

File upload

Details of other organisations you may have applied to for a grant:

Have you ever received an applied behavioural analysis programme before? If yes, please provide details:

Why do you think ABA is the best provision for your child:

Any additional information you feel will help us understand you, your child and family circumstances:

Declaration:

We/I have read the notes and have made a complete and accurate declaration of our/my income and outgoings.

We/I accept that it is at the Trustees discretion as to how families are selected, and as to whether families are fully or partially funded.

We/I understand that if we/I am offered a Bursary for our/my child and accept a place for him/her within your charity, the following terms and conditions will apply:

a. to provide one clean living room dedicated to an intensive ABA therapy programme

b. to be responsible for recruiting and managing our own tutors, including timetabling weekly sessions and submitting signed monthly timesheets along with invoices to The Playhouse Foundation for funding to be released

c. to fully participate and attend every fortnightly team meeting provided by The Playhouse Foundation

d. to consent to video footage of our/my child in order to present evidence of progress

e. to be seen to proactively gather evidence to try to secure an Education, Health & Care Plan throughout the first year

f. to be proactively applying for LA funding from six months of the first year of our/my child receiving intensive ABA therapy provided by The Playhouse Foundation

g. the Bursary may be withdrawn or reduced if:

(i) we/I have failed to produce any additional information required by The Playhouse Foundation to evidence our/my financial circumstances;

(ii) in the opinion of the Trustees, our/my child’s attendance, progress or behaviour no longer merits the continuation of the award;

(iii) we/I are more than 14 days in arrears in respect of any amount due and owing to The Playhouse Foundation;

(iv) there is a material change in our/my circumstances;

(v) the Charity’s resources are insufficient to maintain the level of award.

h. the Bursary will be withdrawn and the value of any amount of the Bursary previously credited against our/my child’s fee account will become repayable to the Charity forthwith if we/I have fraudulently, knowingly or recklessly provided false information in relation to the award of the Bursary.

I have read and accepted this document.

Signature

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Date

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