Scholarship

Your Name (required)

SelfImmediate Family MemberSignificant Other/SpouseFriendOther

Email Address (required)

Phone Number (required)

Date of Birth

Address

City

State

Zip Code

Applicant’s Parent/Guardian(s) Name

Total Household *Income (including wages)

Number of Household Members

Do You Have Health Insurance?

If Yes, Name of Insurance Company

Do You Have Any Other Health Coverage?

If Yes, Please Explain

Did You Graduate High School?

Have You Ever Been To Treatment Before?
YesNo

Letter of Recommendation:
A letter of recommendation must be submitted for each applicant. The letter should attest to the applicant’s character and citizenship qualities.

Essay:

Each applicant must submit a type written essay that discusses the theme of:

“How will my education and training assist me to make a difference in the field of addiction and the recovery community”

Describe how you will make a positive contribution to the field of addiction. Give a specific example on how recovery from drugs and alcohol makes a difference in the life of the individual and their family.