Scholarship - Reapply

For those reapplying for scholarships, please use this form

Parent First Name

Parent Last Name

Mobile Phone

Alternate Phone

Child First Name

Child Last Name

Child's Age

Date of last scholarship award

City

Zipcode

Were you able to use all the funds from your previous scholarship?

Do you have other funding such as GCSS, NOW/COMP Waiver, or DBHDD? Check all that might apply

Select...

If you have not yet applied for any waiver, please tell us why

Select...

If there are any changes since you last applied, please list these here. This would include name, phone, address, or anything about your situation that would need updating

What have you done to help keep our scholarship fund growing?

Select...

Screenshot

Upload your screenshot for your FB fundraiser, HelloDonor enrollment, etc.

Additional screenshot

Upload a second screenshot here

Would you be willing to respond to a short survey on your experience with Special Needs Respite?