Scholarship Application

About the Applicant

The “applicant” refers to the individual who will benefit from the therapy being requested.
For historic scholarship tracking purposes, please include any former names that the applicant has had.
The applicant must have a diagnosis from a physician, psychologist or psychiatrist BEFORE applying.
Please list the formal primary and secondary diagnoses or disabilities. (Examples: Autism Spectrum Disorder, cerebral palsy, profound hearing loss, mitochondrial disease, sensory integration dysfunction). Please note: if you are selected to receive a scholarship you will be asked to provide proof of diagnosis.
This may include likes/dislikes, disposition, hobbies, etc. This is an opportunity to introduce the applicant to the scholarship committee.

Therapy Information

Please mark therapies received at school with an "S" and those received privately with a "P" (for example, "Vision Therapy - S").
Name the specific type(s) of therapy for which you would use the scholarship. (Example: Physical Therapy, Speech Therapy, Occupational Therapy, Therapeutic Horseback Riding)
Explain how the applicant will benefit from the therapy you are seeking a scholarship for. Explain how this therapy has helped the applicant in the past, or if the therapy is new, explain the goals you have for therapy.
For example, if a therapy costs the applicant $100 per session after insurance or discounts, and the applicant would ideally receive 4 sessions per month, the total cost would be $2400 for 6 months. For experiences that are charged as a package, like a therapy camp or 6-week horse therapy session, list the total registration cost. Please give your best estimate of your cost, and use the optional Therapy Cost Comments box below if you want to let us know details about how you arrived at this number.
This field is optional. You can use it to share any additional information about how this therapy is billed that would help us understand how you calculated the out-of-pocket cost in the question above.
(Up to $1000.00)
You will need to check your insurance policy before answering this question. Always check your exact coverage before you apply. Note that if you are selected to receive a scholarship, you will be required to submit your insurance benefit information from your insurance carrier.
If your therapy provider is not listed, select "Request a New Provider" and enter their information below. We are always bringing on new partners. However, it is recommended that you contact Family Hope Foundation to discuss a non-listed therapy provider.

Applicant Household Information

If over 18, independent and applying for yourself, check “Self.”
Parent / Guardian #1 or Self

Complete contact information for custodial parents/guardians below. If over 18, independent and applying for yourself, list your own contact information.

Applicant must reside in one of the counties listed in order to qualify for a scholarship.
This is the email address where all communication about the scholarship process will be sent. Please be sure to accurately enter an email address that you check often.
Parent / Guardian #2 (if applicable)
Explain how receiving a therapy scholarship will be financially beneficial to your family. Therapy scholarships are awarded based on need so you must clearly demonstrate a financial need.

Designated Scholarship Program

Our Designated Scholarship Program is a program that allows groups, service clubs or businesses to sponsor a scholarship recipient. Partnering with other groups allows Family Hope Foundation to raise additional funds and provide assistance to more families. Receiving a scholarship through our Designated Scholarship Program requires the applicant family to:

  • Sign a release that gives us permission to share the applicant’s first name, age, disability, story and therapy needs with the sponsoring group to create an individual connection. No personal contact information will be disclosed.
  • Be willing to adhere to the request of the sponsoring group for a personal connection. These requirements vary by sponsoring group, but could be things such as:
    • Send a personal thank you note with a photo to the sponsoring group.
    • Attend a meeting of the group to introduce your child and say thank you.
    • Write a letter after the applicant's therapy is complete, explaining its value and your gratitude.

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