National Medical Scholarship Application 2025

Please use this form to apply.

You have to select the doctor you want to work with should the scholarship be awarded. IT IS REQUIRED by the review committee that you do the following:

1- Make sure the doctor is taking new patients (unless you are applying for the scholarship to continue treatment with your current doctor).

2- If you are not sure of your choice of doctor PLEASE DO NOT APPLY. Please contact your TACA Parent Mentor, or TACA's online community to help you research your options and determine what doctor matches your child's needs best.

3- You can NOT split the funding between two doctors.

4 - UNDERSTAND - If the scholarship is awarded, ONE check will be sent directly to the doctor/clinic to use for treatment. Any travel or accommodation costs are NOT covered by the scholarship. There MAY be cases where some funds can be used for lab work and/or supplements but that would need pre-approval from the doctor's office.

5- KEEP IN MIND - Some doctors charge a new patient registration/membership or concierge fee. The scholarship may be used for that BUT take that into consideration when selecting a doctor because it will reduce the amount available for treatment.

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Contact Information (TACA will never, ever sell your information)

First Name Last Name

Race

Street Address Address Line 2 (Optional)

Postal Code City State

Email Home Phone (Optional)

Facebook Profile URL

Yes, sign me up for email updates.

Remember me so that I can use FastAction next time.

(Optional)

Additional Information

Have you received a TACA Medical Scholarship Previously?

First and Last Name of Child/Adult that will benefit from the scholarship.

Diagnosis

Have you been a member of the TACA Hope and Help for Autism Facebook group for at least three months?

Please list the name of the Facebook profile you use as a member of the TACA Hope and Help for Autism group.

Provide the name of your TACA Parent Mentor, if you have one. (Optional)

List any TACA Events you have attended.

List any TACA Downloads or Checklists you have downloaded.

What gender is the person with ASD?

Year of birth of individual with ASD.

Anyone in your house hold Native Hawaiian or of Native Hawaiian Descent?

What is your combined annual household income (Gross) PLEASE INCLUDE ALL MEMBERS OF HOUSEHOLD, FEDERAL/STATE BENIFITS, CHILD SUPPORT/ALLOMONY.

Number of people living in your household.

Please provide a brief statement about why you feel your child/adult will benefit from this scholarship.

Please outline what functional medical interventions you are currently pursuing and how this scholarship will help.

Please explain how you plan to fund functional medical treatment after this scholarship is expended.

List any medical conferences you have attended (TACA conferences or others).

Name of the doctor and/or clinic you have selected to receive this scholarship if awarded.

Full address of the doctor/clinic you have selected.

Phone number of the doctor/clinic you have selected.

Website of the doctor/clinic you have selected.

Email of the main contact for the doctor/clinic you have selected that TACA can contact (office manager, billing department, etc).

All information submitted to TACA shall remain confidential. Please note that, pursuant to California and federal law requirements, TACA reserves the right to follow up to ensure any approved scholarship was actually used for its intended purpose.

I certify that the information on this form is true and complete to the best of my knowledge.

I understand that transportation or accommodations will not be provided with this scholarship.

By my electronic signature (e-signature) below, I hereby declare the above statements are true and correct to the best of my knowledge. I have clear and convincing documentation of all above statements and can provide these documents upon request of the TACA Scholarship Program Team.

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