Scholarship Application - The Hope of Shades Foundation

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In order to be considered for a scholarship, the attached application form must be completed in its entirety and be completed accurately and truthfully. The applicant must be forthcoming with information requested and provide additional information or clarity as needed. Scholarships will be considered on an individual basis and reviewed by the application review committee on a first submitted, first reviewed basis. In addition, applicants will be required to submit to a background check and a finance/credit check at their own expense as detailed below. The Foundation will sponsor a proportion of a successful applicant’s treatment costs up to a maximum of $10,500. Applicants will be required to contribute financially to their treatment in addition to any scholarship amount awarded. If a successful applicant forgoes treatment early, The Foundation will not be responsible for any remaining outstanding treatment costs and the applicant will be personally liable to settle any outstanding costs that may fall due.

All fields are compulsory. If the question does not apply, type ‘n/a’ or ‘0’ if it is a number field.

Apply for scholarship

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Contact information

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (home)*

Phone (cell)*

Phone (work)*

Your personal details

Marital Status*

Are you a U.S. Citizen?*

Yes

Height*

Weight*

Date of birth*

Social Security #*

Your Residence*

How long have you been in this residence?*

Monthly payment*

Current?*

Yes

Emergency contact

Emergency contact name*

Relationship*

Phone*

Employment

Employer*

Work Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long have you worked there?*

Income / month*

Insurance Information

Insurance*

Relationship to Insured*

Group / ID*

Address*

Contact*

Marital Status*

Spouse name*

Phone (cell)*

Phone (work)*

Number of Dependents (children)*

Other Dependents*

Financial information

Monthly income (self)*

Monthly income (spouse)*

Monthly income (other)*

Do you qualify for public assistance?*

Program?*

Extraordinary family expenses*

(Items other than expected monthly cost)

Real property payment*

Mortgage balance*

Bank Balances

Checking*

Savings*

IRA*

Stocks*

Investments*

Any other assets*

Expenses / Liabilities

Car Make / Model / Year*

Payments / month*

Balance*

Health Ins.*

Auto Ins.*

Life Ins.*

Other Ins.*

Gas / Electricity*

Water*

Cell Phone*

Cable / Internet*

Other*

Child Daycare*

Additional Care*

Credit Card Debt

Credit Card #1 Balance*

Monthly payment*

Credit Card #2 Balance*

Monthly payment*

Credit Card #3 Balance*

Monthly payment*

Credit Card #4 Balance*

Monthly payment*

Misc Loans*

Other*

Current Circumstances

Currently seeking treatment for (check which box applies):*

Compulsive overeating

Anorexia

Bulimia Binge / Purge

Other

Please rate from 1 to 10 (10 being the greatest) the severity of this addiction:*

Please rate from 1 to 10 (10 being the greatest) the urgency to seek treatment:*

Have you been convicted of a felony?*

Yes

If yes, please provide additional information:*

Do you have any outstanding warrants or a pending lawsuit?*

Yes

If yes, please provide additional information:*

Have you been mandated to attend treatment by a judicial system?*

Yes

If yes, please provide additional information:*

What is the estimated dollar amount needed?*

N.B. Maximum award is $10,500.

Have you received funds from The Hope of Shades Foundation in the past?

Yes

Where would you like to receive treatment?*

N.B. Only recognized accredited facilities with specialist eating disorder treatment programs will be considered

Are you an employee or a family member of an employee of a treatment facility in the US?*

Yes

Are you currently employed?*

Yes

If yes, would obtaining time off from your employer be an issue?*

Yes

Number of family members in household:*

Do you have dependents?*

Yes

If you were to attend treatment, would you be able to arrange care for your dependents?*

Yes

Have you been treated for addiction before?*

Yes

If so, where, and how long ago?*

Are you in relapse currently?*

Yes

Longest period of abstinence?*

Do you have a family history of addiction or substance abuse?*

Yes

Have any immediate family members applied to or received funds from The Foundation?*

Yes

Are you an officer for any foundation currently?*

Yes

If so, which one?*

Do you see a therapist on a regular basis?

Yes

If so, how often?*

Do you have face to face 12 step meetings in your area you attend?*

Yes

Do you attend phone or online 12 step meetings?*

Yes

Statement*

Please provide a statement (500 words or less), on who you are, how disordered eating has impacted your life, and why you are seeking treatment. Please include any and all information that you think will assist the application scholarship committee including such items as what makes you feel like this is right for you, how will treatment help you and why you are seeking treatment now.

Application for Financial Assistance

The Foundation provides scholarships and grants to assist those seeking treatment for eating disorders and the disorders resulting from and/or relating to such eating disorders. Our ability to provide assistance depends on a variety of factors including but not limited to the determination of suitability, need and ability to pay. The Foundation prohibits discrimination against and harassment of any employee or any applicant because of race, color, national or ethnic origin, age, religion, disability, sex, sexual orientation, gender identity and expression, veteran status (special disabled veterans, disabled veterans and Vietnam-era veterans), or any other characteristic protected under applicable federal or state law. All members who are responsible for the development and implementation of treatment programs or activities are charged to support this effort and to respond promptly and appropriately to any concerns that are brought to their attention. The Foundation is not liable for any loss, injury or deaths sustained while participating in any treatment program.

Upon leaving treatment, I agree to follow the treatment plan as outlined from the treatment facility and any additional programs set forth for my recovery.

Additional Information Required

As part of this application process, you will be required to provide, at your own expense, a recent credit report and criminal background check as well as your most recently filed tax returns or if you have do not file tax returns, your 3 most recent consecutive bank statements. No applications will be considered until ALL of these items are received and reviewed by the Foundation’s scholarship committee.

You may use any of the companies listed below:

For Credit Reports

By law, you can get a free credit report each year from the three credit reporting agencies (CRAs). These agencies include Equifax, Experian, and TransUnion.

AnnualCreditReport.com is the only website authorized by the federal government to issue free, annual credit reports from the three CRAs. You may request your reports:

Online by visiting AnnualCreditReport.com
By calling 1-877-322-8228 (TTY: 1-800-821-7232)
By filling out the Annual Credit Report request form and mailing it to:
Annual Credit Report Request Service PO Box 105281 Atlanta, GA 30348-5281

Credit reports show your personal financial information, including:

Bill payment history
Loans
Current debt
Bankruptcy history
Lawsuit records

In most cases, your credit report will not include your credit score.

For Criminal Background Check

For a fee (currently $18 and subject to change), the FBI can provide individuals with an Identity History Summary, often referred to as a criminal history or “rap sheet”—listing certain information taken from fingerprint submissions kept by the FBI and related to arrests and, in some instances, federal employment, naturalization, or military service.

If the fingerprint submissions are related to an arrest, the Identity History Summary includes the name of the agency that submitted the fingerprints to the FBI, the date of the arrest, the arrest charge, and the disposition of the arrest, if known. All arrest information included in an Identity History Summary is obtained from fingerprint submissions, disposition reports, and other information submitted by authorized criminal justice agencies.

Get Your Identity History Summary/Rap Sheet (or Proof One Does Not Exist)

The fastest option is to submit your request online, for both Identity History Summary Checks and Identity History Summary Challenges.

Visit edo.cjis.gov.
Follow the steps under the “Obtaining Your Identity History Summary” section.

If you submit a request electronically directly to the FBI, you may visit a participating U.S. Post Office location to submit your fingerprints electronically as part of your request. You may go to any of the participating U.S. Post Office locations nationwide upon completion of your request. Additional fees may apply.

If you choose to use a U.S. Post Office location, you must complete your application and payment electronically prior to visiting a U.S. Post Office location to submit your fingerprints electronically as part of your request.
If you choose not to use a U.S. Post Office location, then you may still mail your completed fingerprint card, along with your confirmation email received when you started your electronic request, to the address listed on your confirmation email. The request will continue to be processed as an electronic submission once the completed fingerprint card is received.

Contact:

Email: identity@fbi.gov
Phone: (304) 625-5590

Confidentiality:

Confidential information contained within or related or appended to this application in whatever form will be used for the purpose of completing the scholarship application assessment process and to determine what, if any, financial contribution may be forthcoming from The Foundation. Parties who may review the confidential information provided by the applicant may include but not be limited to Board Members of The Foundation and professionals and staff involved in the treatment of eating disorders, addictions and mental health conditions or any such other person or entity as determined suitable or necessary by The Foundation in its absolute discretion.

Liability:

None of The Foundation, its Board of Directors, affiliates, or volunteers are responsible for any physical injury, property damage, emotional distress, treatment decisions, treatment plans, medical direction or prescriptions or any other treatment-related matter. Those decisions are exclusively between the applicant and the treatment facility.

Monetary Decisions:

Scholarship decisions will be decided based upon the suitability of an applicant, available funds, cost of treatment, after care availability, financial need, willingness, family participation and need for treatment and any other factor determined as relevant by The Foundation in its absolute discretion. Any decision of The Foundation will be final and not subject to appeal or review by an applicant or any other person or entity.

Re-application:

If an applicant is not awarded a scholarship, he/she/they may not reapply unless given specific permission from The Foundation; however, in the event a decision is made purely on the availability of scholarship funds, an application may be held over for further consideration at a later date.

Applicant Financial Responsibility Agreement

Financial Statement:
Any and all expenses incurred by or with respect to a scholarship recipient’s treatment over and above the approved scholarship award made by The Foundation are the sole responsibility of the applicant. Any financial arrangements including the collection of payments are between the applicant and the treatment facility. This includes incidental fees including travel, prescriptions, personal items, stamps, paper, books, materials, outings, and any other fees or incurred with the treatment facility or in relation in any way to an applicant’s treatment.

If a scholarship recipient leaves treatment before the funds are earned or distributed, the applicant is responsible for paying any and all fees to the treatment facility that he/she/they have incurred.

Any awarded scholarship will be paid directly to the treatment facility upon verification of admission and invoicing from the treatment facility. No funds will be distributed directly to the applicant.

Confidentiality Agreement

I agree that the receipt of this scholarship is strictly confidential unless authorized by The Foundation in writing and any conversation around finances, available funds, balances on accounts will be discussed solely with the Executive Director, Finance Director or other such similar person at the treatment facility.

Any reference whether verbal or however so made, by a scholarship recipient whether made before, during or after treatment with other clients, treatment facility personnel, or anyone else would constitute a breach of this confidentiality agreement and any funds distributed may be subject to revocation (removal) and forfeiture.

Willingness and Family Participation Statement

Willingness: I agree that I am applying for treatment of my own free will and will be available and willing to attend treatment and stay the recommended time frame until the scholarship is exhausted or until facility staff recommends otherwise.

I agree to follow the recommendations of the staff at the treatment facility for a treatment plan while I am in the treatment facility’s care including but not limited to attending 12 step recovery meetings, therapy appointments, reading, and writing assignments, and group meetings.

I agree that I will participate in treatment activities to the best of my ability and will be open and willing to following directions.

I agree that I will provide a written testimonial of at least 100 words for use by The Foundation to assist in its fundraising for the purposes of providing treatment to other future applicants. I acknowledge that no identifying information will be used by The Foundation in this respect other than my first name and the State I reside in without my express permission.

Family Participation:
I agree that if asked, I am willing to invite family members to family week to further my recovery if it is recommended by the staff during treatment.

Childcare:
If applicable, I acknowledge that if I am selected for a scholarship, I have a place for my child or children to stay that is safe.

Sign

Signature*

If using a touch pad device you can sign directly in the box. Alternatively print this page to sign with a pen.

Name*

Date*