Cynthia Carroll Inclusion Scholarship – Application Form

Name of Nominee *

Please provide the following information about the nominee.

Current Role/Position *

Organization/School Name *

Work Address *

Email Address *

Phone Number *

Full Name of Nominator *

If you are submitting a nomination on behalf of someone else, please provide your contact information and relation to the nominee. If you are self-nominating, please enter N/A to this and the next three questions.

Relationship to Nominee *

Email Address of Nominator *

Phone Number of Nominator *

Please describe how the nominee has made a direct impact on the lives of Autistic individuals in an educational setting. Maximum 300 words. *

How has the nominee demonstrated a commitment to promoting accessibility and inclusion for Autistic individuals? Maximum 300 words *

Please provide examples of the nominee’s advocacy and collaboration with other educators, families, or community organizations to support autistic individuals. Maximum 300 words *

How does the nominee’s work align with the values of Cynthia Carroll, particularly in advocating for the autism community and promoting equitable access? *

Letter of Support/Recommendation *

Click or drag a file to this area to upload.

A letter from a colleague, supervisor, or community member who can speak to the nominee’s impact and contributions.

Nominee’s Professional Biography or Resume *

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A brief bio or resume outlining the nominee’s experience and achievements.

Additional Evidence (optional)

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Any additional documents, such as reports, testimonials, or examples of the nominee’s work, that support the nomination.