Readthese Guidelines Thoroughlybeforecompletingthe Application Form!

ScholarshipGuidelines

FamilyHopeFoundation

70868thAvenue

Jenison, MI 49428

(616)780-3839

Readthese Guidelines thoroughlyBEFOREcompletingthe application form!

General Information:

Purpose: Toassistfamiliesofindividualswith specialneeds byprovidingfinancial assistancefor therapyrelated servicesthatmaynototherwisebe covered byinsuranceorother fundingsources.

Typesof Support: Examples ofeligibletherapyrelatedservicesinclude,butarenotlimitedto, physicaltherapy, occupational therapy, speech therapy,musictherapy,massagetherapy,hippotherapy, Applied BehavioralAnalysis, psychologyandpsychiatry.

Limitations:Noscholarships aregiven fororganizations/businesses, fundraisingdrives, debt reduction(expenses incurred fortherapyreceived priortothescholarshipaward),medication,transportation,technology,equipment, diagnosticor therapeuticevaluations, respiteor travelexpenses.

GeographicFocus: AwardsarefocusedintheWestMichiganarea.

ScholarshipAmountsandPayment:Scholarships willbeawarded inamountsupto andincluding $1,000with special considerationgiventothosewhohavenotpreviouslyreceived funds fromFamilyHopeFoundation. Scholarshipmoney willbe paiddirectlytotheapproved therapyprovider.Funds will notbedistributedincash and willnotbegiven tothe recipient.

ApprovedTherapyProviders: FamilyHopeFoundationforms apartnershipwitheach therapyproviderwho receives funding for a scholarship recipient.Providersmustmeet theFamilyHopeFoundation“ProviderGuidelines” requirementsandbeapproved bytheBoardofDirectors asaCommunityPartner. Toseea listof currentlyapproved TherapyProviderPartners,visitourwebsiteat ProgramsandScholarships.

If youwouldliketoapplytoatherapyprovidernotlistedhere, pleasecalltodiscuss- (616)780-3839.

Other: Applicationswill beaccepted andconsideredwithoutregardtosex,religion, ethnic background, race or nationalorigin. However, therecipientmustmeetcriteria fortherapyinordertoreceivethe scholarship.

ContactInformation: Ifyouhavequestionsregardingtheapplicationprocess orscholarshipprogram, contactFamily

HopeFoundationat(616)780-3839or .

Application Process Information:

ApplicationDue Dates: Applicationswillbeacceptedandfunds distributedtwiceayear.Applications due onMarch

1stwillbeaccepted no earlierthanFebruary1st.Applications dueonSeptember1stwillbeaccepted noearlierthan

August1st.If thedeadlineis onaweekendor holiday,applications willbeduethe followingbusinessday.

ApplicationSubmission:

Applicationsmustbecompletedonour formand receivedby mail orhanddeliveredby5:00pmonthedue dateto:FamilyHopeFoundation,70868thAvenue,Jenison, MI49428.

Applications donotroll-overto thenextscholarshipcycleandmustberesubmitted eachtimeascholarshipis desired.

Applicationswillnotbeaccepted electronicallyorbyfax.

Useof theexterior dropboxis onlyforweekends andafterhours.Takeall paperworkinsidethebuildingif the officeisopen.

Youmustsubmitthreetotal stapled copiesofyour application.

Otherthananynecessaryadditional sheetstoanswerthe narrativequestions, doNOTincludeanyother documentation, photos, etc. withyourapplication.

AfterApplying: Applicantswill be notified withintwomonths oftheapplicationdeadlineas towhethertheir scholarshiprequestisbeingfulfilled (notifications to besentbyMay1storNovember1st).Atthattime,accepted applicantswillberequiredtosubmit furtherverificationandfinaldocumentation.This documentationmustbe receivedwithinonemonthofthe request.

Completingthe ApplicationForm:

*Everyquestionmustbeanswered,accordingtothedirections,fortheapplicationtobecomplete. Incomplete applicationswillbepenalized or notconsidered for funding.

Applicant Information:

The“applicant”refersto theindividual with special needs whowill benefit from thetherapy being

requested.

Question 5-6:Pleaselisttheformal primaryandsecondarydiagnosesor disabilities. (Examples: Autism Spectrum Disorder, cerebral palsy,profoundhearingloss, mitochondrial disease,sensoryintegrationdysfunction)

Question7:Check ONEdisabilitycategory only.

Question 8:Complete the narrative.Youmayuseanadditional sheetof paper for this questionif necessary.

General Information:

9and9a: Checkyesor noappropriately.

Question10:Giftof Hopeis aprogramof FamilyHopeFoundationthat allowsgroups, serviceclubsorbusinessesto sponsorascholarshiprecipient.Partneringwithothergroups allowsFamilyHopeFoundationtoraiseadditional funds andprovideassistanceto morefamilies.ReceivingaGift of Hopescholarshiprequires theapplicantfamilyto:

Sign areleasethatgives uspermission tosharetheapplicant’sfirst name,age,disability, storyandtherapyneeds with thesponsoringGiftofHopegrouptocreatean individual connection.Nopersonal contactinformation willbedisclosed.

Bewillingtoadheretotherequestof thesponsoringgroupforapersonal connection.Theserequirements varybysponsoringgroup,butcouldbethings such as:

oSendapersonal thank younotewith aphototothe sponsoringgroup,

oAttendameetingof thegrouptointroduceyourchildandsaythankyou,

oWritealetter aftertheapplicant’stherapyiscomplete, explainingitsvalueand your gratitude.

Question11: Thetherapy provideristhe organizationor business,nottheindividual therapist, unlesstheyarethe same.(Example: If youwanttoseeJulieJonesatABCTherapyShop, then thenameoftheTherapyProviderisABC TherapyShop. If thenameof JulieJones’practiceis JulieJones,thenthe answerwouldbeJulieJones.)

Requestscanbemadeto only onetherapyproviderper application.(Example:Youmayrequesta scholarshipfor OTandspeech atthe sametherapylocation.Youmaynotrequestyour scholarshipbesplitto receiveOTat onelocationandspeech atanother location.)

It isrecommendedthatyoudesignateaspecifictherapyproviderthatyouwouldliketoparticipatewith.

If youdonotknowwheretogofortherapy,weurgeyoutodothatresearchbeforefillingoutthis requestfor fundingsupport. YoucanusethelistofourTherapy ProviderPartnerslocatedonourwebsiteas aguide ( FamilyHopeFoundationfor assistance(616-780-3839).

Youmayapplyto a provider whoisnotcurrentlyaTherapy ProviderPartner.Weare always bringingonnew partners. However, itis recommended thatyoucontactFamilyHopeFoundation (r616-780-3839) todiscussa non-listedtherapyprovider.

Question12:Listhow youheard aboutFamilyHopeFoundation.

Family Information:

Questions 13-17: Identifycustodial parents/guardians.If over18, independentandcompletingtheform yourself,

check“self.”Completeallcontactinformation.

Question18:Indicatehowmanychildren andhow manyadults liveinyour home, including yourself,whoare dependenton your income.

FinancialInformation:

*This is anapplicationforfinancial assistance; youmustprovefinancialneed. Pleaseconsiderthatsincethepurpose of thescholarshipistosupporttherapynotcovered byinsurance, everyapplicantis applyingfor thatreason.

Question19:Listthescholarshipamountyouwouldliketoreceive,not toexceed$1,000.

Question20:Indicatethecostofthis exacttherapyhowitis billedbytheprovider. (Example:$100perhour or

$800perweek. Writein anyuniquesituations such as$1,500for3weekintensive.)

Question21:Checkall items thatdescribethetype of medical insurancethe applicanthas.

Question 22:Checkthecorrectresponse. Youwill need to checkyour insurance policybeforeansweringthisquestion.Therehavebeenalotof insurancechangesrecently.Alwayscheckyour exactcoveragebeforeyouapply. Notethat ifyouareselectedtoreceiveascholarship,youwillberequired tosubmityourinsurancebenefit information fromyour insurancecarrier.

22a.Iftheanswer to 22isNooriftheapplicantdoes nothaveanyinsurancecoverage, leaveblank. If youanswered yes,toquestion22, listhere your deductible, co-pays,renewal date,coverageamount,etc.

Question23:Checkwhichoptionbestdescribesyourfamily.

Question24:Checktheappropriatebox.If thereis anyoneelse (otherthantheapplicant)intheimmediatefamily

(parentsor siblings)whohas adisability,explainwhoandthetypeof disabilityinthenarrativefor question25.

Question25:Completethenarrative,explaininganyitems checkedin this section, plusanythingelsethat thereview committeeshouldtakeintoconsideration.Anadditional sheetmaybeattachedtocompletethisquestion.

TherapyInformation:

*Completethissectionfor thetherapyprovideryouchoosetoreceivetherapyfromforthis scholarship.

Question26:Namethe specifictype(s)of therapyforwhich youchoosetousethescholarship. (Example:Physical

Therapy, SpeechTherapy,Psychology,TherapeuticHorsebackRiding)

Question27:Thetherapy provideristhe organizationor business,nottheindividual therapist, unless theyare the same.(Example: If youwanttoseeJulieJonesatABCTherapyShop, then thenameofthe therapyproviderisABC TherapyShop. If thenameof JulieJones’practiceis JulieJones,thenthe answerwouldbeJulieJones.)

It isrecommendedthatyoudesignateaspecifictherapyproviderthatyouwouldliketoparticipatewith.

Questions28and29: Identifyifyouhavereceived anevaluationand/or servicesfromthis particular provider.

Question30:ListALLtherapies, includingwhat youareapplyingfor, inthissection.Indicateif theapplicantis currentlyreceivingtheminschool (S)orprivately(P)or if a therapyisnotcurrentlybeingreceived, butitis atherapy youwouldliketodo(D).

Question31:CheckYesorNo.

31a:Maybeleftblankiftheanswerto31is No.

Question32:Completethenarrative.Youmayuse anadditional sheetof paperforthis questionif necessary.