GRANT APPLICATION - LOCATOR DEVICE

Requirements for grant application:

  1. Individual must be diagnosed with an Autism Spectrum Disorder.
  2. Individual must reside within the region served by the Autism Society Greater Harrisburg Area (Adams, Cumberland, Dauphin, Franklin, Juniata, Lancaster, Lebanon, Mifflin, Northumberland, Perry, Snyder, Union and York.)
  3. Individual must be at risk due to verified elopement behaviors.
  4. All documentation must be uploaded on submission of this form. DETAILS HERE
  5. Individual may be awarded only one approved grant per year.

Section 1: Family Information

Name of individual who will wear the device:

Parent/Guardian 1:

Are you a National Member of the Autism Society?*

Parent/Guardian 2:

Are you a National Member of the Autism Society?

Person completing grant request

If you are not a parent or guardian of the individual who will be wearing the device and are filling this form out for them, please enter your information below.


Section 2: Device And Contract Information

Have you already entered into a contract with a locator device provider?*


Person entering into contract with device provider:*



Section 3: Documentation

The Autism Society Greater Harrisburg Area (ASGHA) requests that you provide documentation from a medical doctor verifying an Autism Spectrum Disorder diagnosis and elopement behaviors and risks.

After successfully completing and submitting the form, you will be required to upload this documentation. YOUR GRANT REQUEST CANNOT BE COMPLETED WITHOUT IT.

Documents can be uploaded in the following formats:

  • PDF
  • Word (.doc, .docx)

Please feel free to include additional information about elopement behavior from any person, including you and your family, familiar with your child. (Ex. Teachers, BHS, TSS). Attach any stories or observations (any information) to form.

Person 1

Person 2

Person 3

Please provide other information you feel is important. (Tell us your story)


Section 4 (optional)

Please answer the following questions to help us better serve our autism community.

What is the household annual income?


I certify that:

  • The information provided in this application is true and correct to the best of my knowledge.
  • Applicant agrees to provide additional information upon request, including financial information, to the Board of Directors or Grant Committee.
  • The applicant understands that the contract for the device is between the applicant and the device provider. Even though the Autism Society of Greater Harrisburg Area may provide a grant to help defray costs for the device, the Autism Society of Greater Harrisburg area is not a party to the contract for the device.
  • The applicant understands that the device funded by the grant may involve hazard to the applicant. Notwithstanding that the Autism Society of Greater Harrisburg Area may help fund the device; the Autism Society of Greater Harrisburg Area does not prescribe, approve, or supervise the device in any way. The Applicant expressly and specifically assumes the risk of injury or harm in the use of the device and releases the Autism Society of Greater Harrisburg Area from any liability, illness, death, or property damage resulting from the device.
  • The applicant understands that, if the grant is approved, the applicant must remit documentation of payment to qualify for grant payments.

Submit