Program Request *

Youth Programs

Veterans Programs

Mental Health Programs

Have you reviewed and understood the Scholarship Criteria & Guidelines? *

Yes

No

Participant Type *

Existing participant (has previously participated in programming)

New participant (application packet & physician's referral submitted)

Prospective participant (please do not submit this form; contact us to receive an application packet)

Participant's Name (First & Last) *

First Name

Last Name

Phone

(###)

###

####

RELATIONSHIP TO CHILD *

Parent

Non-parental guardian

Other

I understand that there is a waiting list for this program, and that a formal application form w/ physician's referral needs to be submitted in order to apply. *

Yes

I understand that scholarship recipients are required to pay 20% of their lesson fees, and that all all fees are due at least one week prior to the first lesson. Fee schedule as of March 1, 2024: $75 per 55-60 minute lesson $60 per 30-35 minute lesson *20% of tuition as of March 1, 2024: $15 per 55-60 minute lesson $12 per 30-35 minute lesson

Yes

No

I am interested in requesting scholarship assistance for the following: *

2 x 30-min Lessons - $120 ($24 rider fee)

4 x 30-min Lessons - $240 ($48 rider fee)

6 x 30-min Lessons - $360 ($72 rider fee)

2 x 60-min Lessons - $150 ($30 rider fee)

4 x 60-min Lessons - $300 ($60 rider fee)

6 x 60-min Lessons - $450 ($90 rider fee)