New Customer Registration Form

Anchor of Hope Foundation Scholarship Application

*Please note that we are only accepting applications from families that reside in the state of Georgia. Please fill in the form below.
Scholarship Recipient's Name

First NameLast Name
Child's Diagnosis:
Proof of Diagnosis (Please attach proof of diagnosis from a medical health care professional. Please note we do not accept IEPs as proof of diagnosis)

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Child's Age
Child's Birth Date
Child's Gender
Child's Race (optional)
Parent/Caregiver's Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County or District
How did you hear about the Anchor of Hope Scholarship Program?
Signature

First NameLast Name
E-mail*
Description of Goods/Services Requested * Please be as specific as possible and provide detail information which will allow us to process the request more efficiently. Please provide Provider/Vendor Name, Address, Contact Person, Cost of Item and Item Number if applicable:
Total Amount of Funds Requested and Cost Breakdown* Please note we are only able to award up to $250 per person per calendar year. In cost breakdown please list how much the scholarship will provide in the total cost. It also helps the board to have an invoice from the service provider for the services/goods that are being rendered:
Have you received assistance from Anchor of Hope before? If yes, please specify.
Have you sought funding from other sources? If yes, please list:
Have you received funding from other sources for this request? If yes, please list from whom:
What goal(s) do you hope to accomplish through the provision of this therapy, service, or equipment?
Please provide any additional information you believe would assist the grant committee in its decision.
Will you be willing to return a questionnaire to the foundation which will be a follow up of your experience with the provider of the supplemental care scholarship and whether your goals were met?

YesNo
Are you willing to submit a picture of the applicant so that we can share your story (only first name) with our supporters?

YesNo
I agree to the terms and conditions of Anchor of Hope Foundation’s Privacy Policy.

First NameLast Name
Date of Signature

MonthDayYear
Date
I agree with the terms and conditions of Anchor of Hope Foundation’s Release and Waiver of Liability.

First NameLast Name
Date of Signature

MonthDayYear
Date
I agree with the terms and conditions of Anchor of Hope Foundation’s Publicity and Photo Release agreement.

First NameLast Name
Date of Signature

MonthDayYear
Date
Should be Empty:

Anchor of Hope Foundation Scholarship Application