Scholarship Application

Applicant's First Name *

Applicant's Last Name *

Parent/Caregiver's Name *

Child's Diagnosis *

Proof of Diagnosis *

Please provide a diagnosis from a licensed MD

Additional Diagnosis Documents

If you have additional documents add them here

Additional Diagnosis Documents

If you have additional documents add them here

Age *

Gender *

Child's Race (optional)

Email *

Phone Number *

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Country

State of Residence

County or District

Requested Service/Goods *

Please be as specific as possible and provide item numbers, website links, or any other information to help us understand your needs.

Service Provider Address

If requesting services please let provider's business name, contact person, phone number, and accurate mailing address

Letter of Recommendation

If requesting equipment please provide a letter of recommendation from a health care professional

Total amount of funds requested and cost breakdown for equipment and services *

We only provide up to $250 and funding is sent directly to the service provider, and receipts must be provided for reimbursement of items over $250. Items under $250 will be purchased by us and shipped.

Please list the specific goals you would like to accomplish through this therapy, service, or equipment: *

How will this service/equipment directly benefit your individual?

Have you received assistance from Anchor of Hope before? If yes, please specify. *

Have you sought or received funding from other sources for this request? If yes, please list from whom: *

How did you hear about the Anchor of Hope Scholarship? *

Please provide any additional information you believe would assist the grant committee in its decision.

Will you be willing to return a questionnaire to the foundation which will be a follow up of your experience with the provider of the supplemental care scholarship and whether your goals were met? *

Yes

No

Are you willing to submit a picture of the applicant so that we can share your story (only first name) with our supporters? *

Yes

No

By typing my name, I certify that I have read and agree to Anchor of Hope's Scholarship Privacy Policy *

This policy is found under the Scholarship Policies button on the Scholarships webpage

By typing my name, I certify that I have read and agree to Anchor of Hope's Scholarship Liability and Release Policy *

This policy is found under the Scholarship Policies button on the Scholarships webpage

By typing my name, I certify that I have read and agree to Anchor of Hope's Publicity and Public Photo Release *

This policy is found under the Scholarship Policies button on the Scholarships webpage

"I, hereby certify that, all information contained in the above application is true, accurate, and complete. *

By typing my name above I submit it as my legal signature

Date of Signature *

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