Name *

First Name

Last Name

Phone

(###)

###

####

Rider's Full Name *

First Name

Last Name

Do you currently receive any government assistance? *

SNAP

Medicaid

SSI

WIC

None

Requested scholarship amount? *

Full Scholarship ($150/week)

Partial Scholarship – I can afford a portion each week

How long are you requesting support for? *

1 month (4 sessions)

3 months

Other (please explain below)