Inspired Acres | Financial Assistance Application

Contact information

First name First name

Enter a first name

Last name Last name

Enter a last name

Phone Phone

Enter a phone number

Phone type Phone type

Email address Email address

Enter a valid email address

Email type Email type

Send me email updates & newsletters

Events

Programs

Weddings

General Information

Address

Home Work

Address Address

Enter an address

Apartment, suite, etc. (optional) Apartment, suite, etc. (optional)

City City

Enter a city

Country/region Country/region

Enter a country

State State

Enter a state

ZIP code ZIP code

Enter a zip

Send me lettermail updates & newsletters

Questionnaire

Full Name of the Person filling out this form:

Enter a response

Relationship to Participant:

Enter a response

Participant Full Name

Enter a response

Date of Birth

Enter a response

I am requesting financial assistance for:

Enter a response

Total yearly income includes all sources of income (including child support/alimony and investment income) for all members residing in the home. Bear in mind that we are a charitable organization relying on donor support to serve as many riders as possible, so please be honest about your financial situation. We may ask for more information before making a decision on your application. All information will be kept confidential.

Enter a response

Income: Please list your total household yearly income:

Enter a response

Number of dependents in household:

Enter a response

Are you/have you been eligible for any local, state, or federal funds to assist with therapy or recreation programming?

Enter a response

If yes, please explain:

Enter a response

Do any of these sources cover Inspired Acres fees?

Enter a response

If yes, what amount?

Enter a response

Are any other family members applying for scholarship or financial assistance from Inspired Acres?

Enter a response

Has anyone in your household previously received financial assistance from Inspired Acres?

Enter a response

If yes, when is the last time you received financial assistance?

Enter a response

I certify that all information provided is true and that all income is reported. I agree to inform Inspired Acres of any changes in household income or number of household members in the month in which the change(s) occur. This information will be accompanied by a revised scholarship application. I understand that any co-pay is due at time of service, and I agree to give Inspired Acres ample notice if the rider cannot attend a scheduled session. I understand that chronic absences may jeopardize the rider’s funding.

Enter a response

Confirmation

Click Continue to review our terms and conditions

Continue