Equine Sharing Program, Inc. A 501©3 Not For Profit Organization Scholarship Application The following information and criteria must be met; in order to be considered for a scholarship to be used for therapeutic riding sessions with North American Riding for the Handicapped Association (NARHA) certified instructor and NARHA member center. I wish to apply for a scholarship for equine assisted therapy sessions. I understand that Equine Sharing Program, Inc. does not guarantee funding for clients to participate in sessions. I understand that by contributing to the fee for sessions, it may be easier to obtain funding. Rider’s name:______________________________________________________ Parent/Guardian: ___________________________________________________ Disability/diagnosis:_________________________________________________ Address:_________________________________________________________ Telephone:____________________________Cell:________________________ Email:________________________________Work:_______________________ Please answer the following questions: Family Income ____________________________________________________ Employer:________________________________________________________ Address:_________________________________________________________ Total number of family members living in the household ____________________ Are any other family members disabled?_________________________________ If you answered yes to the above question, please provide details: Describe in detail any Mitigating Factors (such as unusual medical needs or other costs associated with caring for your family member with disabilities) that should be taken into consideration: ____________________________________________________________________ ____________________________________________________________________ Does your health plan cover equine assisted therapy? If yes, at what percent?______ Are you eligible to receive any local, state or federal funds to assist with therapy or rehabilitation?_____________ If Yes, what agency or program?_________________________________________ If Yes, what amount? ___________ Are you applying for a _________ full scholarship _____________partial scholarship If you are applying for a partial scholarship, what amount can you contribute for each session?____________________ Please note the following information before submitting your application. Applicants must not be eligible for any other federal, state or local government program that provide assistance for this type of activity and must be unable to pay for the fees charged by a NARHA member center from personal sources. By signing and submitting this form you are providing us your acclamation for financial assistance on which our selection committee can rely in their determination of scholarship recipients based upon financial need. Any portion of this scholarship not used for this specific purpose must be returned no later than the last day of the session to which this scholarship applies. You are also required to provide us a report showing the disbursements of the scholarship which is also due on the last day of the session. I attest that the preceding information is true to the best of my knowledge. Signed: __________________________________________________________Print Name:
________________________________________________________ Witness: ______________________________Date:_________________Print Name: ________________________, Equine Sharing Program, Inc. Member This application may be returned to the director of the center that your candidate is to attend or you may mail this application to. Equine Sharing Program, Inc. If you have any question please feel free to call 361-937-3991 |