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Global Autism Project Prospective Partners
Application
Center Profile
This section will give us a better idea of your center/institution and the services you provide.
Person filling out this form:
Email
*
example@example.com
Phone Number
Include country code
Center Name
Who is the founder of the center
City, Country
Number of students/consumers at the Center
How many staff (paid and volunteer) work at the Center
How are people referred to the center?
Does the center accept walk-ins
Yes
No
What type of therapy does the center provide?
ABA Therapy
Occupational Therapy
Speech Therapy
Physical Therapy
Sensory Integration Therapy
Diet
Floortime
PECS
Tutoring
Does the center take data on the participants progress?
Yes
No
Sometimes
What is the maximum capacity of your center (is your center at capacity or can more students be served)
How often do staff and volunteers receive training?
Who provides the staff training?
Does the center need more staff to provide services to the students/consumers at the center?
Yes
No
How often do students/consumers attend the center?
Please describe the services the center provides
Example: Home based, center based, workshops, vocational training...etc...
Tell us why the center was created and who is it meant to serve?
Does the center charge a tuition or participation fee?
Yes
No
If Yes, how much?
Are the center's services accessible to middle-low- low income people/families?
Yes
No
If No, please explain why: (ex: transportation, tuition fees, outreach etc...
What age group does the center serve
0-6 years old
6-12 years old
12-18 years old
adults
How do students get to the center?
Public transportation
Private/family owned transportation
Taxi
School bus or van
How is your center funded?
Tuition
Fees for service
Private donation
Personal or family income
Government funding
Grants or scholarships
Fundraising
What is the annual overhead (cost) to run the center?
Partnership
and CoFunding Application
How did you hear about the Global Autism Project?
Describe in detail your center or organization including it's background, current services and future goals:
(Mission, Vision, values...etc...)
What are you hoping to get out of a partnership with the Global Autism Project?
Does the center need additional funding? If so, approximately how much more funding do they currently need to maintain operations/ appropriately serve the individuals with autism in their community?
*Note- the Global Autism Project does not directly fund centers or organizations.
Are the funding sources sustainable (ongoing fundraisers, yearly donations, student fees) or is there a need for sustainable funds?
Yes, funding sources are sustainable.
No, there is a need for sustainable funds.
Does the government currently provide any funding or support for the center?
Yes
No
If yes, what percentage of center's work is funded by the government?
Does your center partner or have special relationships with other local organizations? If so, please list:
Does the center raise awareness about Autism within their community?
What is your center’s commitment to research?
Are any staff in your center/organization interested in BCBA certification/supervision?
Yes
No
Maybe
The cost of partnership with the Global Autism Project is $500,000 USD per year. Through Volunteer fundraising, time, training and support, the Global Autism Project can Cofund this cost up to 96%. If chosen as a partner of the Global Autism Project, how much could you contribute to the total cost of partnership?
Contributions based on country's GDP and Income/wealth status based on World Bank information and Purchasing Power Parity.
City/Country Profile
Does the center have access to quality support and education on Autism Spectrum Disorder?
Yes
No
Where can one access training and support on Autism Spectrum Disorder?
Local Universities
Local Specialists
The internet
Media and Television
How does the community/culture view autism?
How does the community/culture treat people with autism?
What are the requirements for general education children to attend Primary School?
Who diagnoses children with autism in your community?
Are there special education school or supports in your city?
Are there any Board Certified Behavior Analysts provide services for people with autism in your city?
0-5
5-15
15-25
More than 25
Unknown
If any, what are the determining factors for if a child with autism receives access to education?
Verbal, basic math and reading, wealth...etc...
Required Documents
Please attach a PDF or scanned document of 10 letters of support gathered from stakeholders within your community that would support you in your venture to partner with the Global Autism Project:
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See example application for direction or guidance
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Please upload a current service matrix of all the institutions/organizations that are providing services in your city to people with autism. Matrix to include the following: Institution serving children with autism (Name of institution) Director/ Founder Type of institution (e.g. Center, school, hospital) Inclusion? (Yes/ No) Location (City) Socioeconomic status of Children Served Number of Children Served Brief description of the institution/organization
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Please upload pictures of your center
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Please upload a video of some of your services being implemented
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Dissemination Plan
The Global Autism Project requires that our service partners establish meaningful collaboration with members of the community and other institutions/ centers/ school where applicable. Please complete the plan for dissemination below. The goal is to build capacity within your own community to be able to provide quality education and services to individuals with autism.
Please describe in detail what your center's 5 year dissemination plan would be during partnership with the Global Autism Project.
Describe how your center would provide training and outreach to you community and other institutions/organizations.
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