Day Treatment Grant Application

Day Treatment Program Scholarship Application

Funding Cap: Up to 20% of verified eligible expenses per award period

Scholarship funds will be applied directly to eligible program expenses and credited to the applicant’s Day Treatment Program account and distributed evenly across payments. No cash payments will be issued to applicants. Awards are calculated based on verified financial need and available funding.

Applicant Name:

Date of Birth:

Parent/Guardian Name:

Relationship:

Address:

City:

State

Zip Code:

Phone:

Email:

Day Treatment Program Site:

Household Size:

Monthly Gross Household Income:

Free Text

Income information is considered part of the decision-making process, but is not the sole determining factor.

Income Sources (check all that apply):

If other, please describe additional income:

Signature:

Date:

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