OCA Community Impact Application — Orphan Care Alliance

Apply for the OCA Community Impact Scholarship below!

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County of Residence

Phone

(###)

###

####

How did you hear about our scholarship fund?

Name of child/teen that this scholarship is for:

Child's Date of Birth

YYYY

Child Grade Level

Share a little about your foster/adoption/relative placement story:

Program for which you seek financial aid?

If other, for what services are you requesting a grant?

Estimated total cost of the program/therapy:

Please describe how you will benefit from participating in the program that partners with Orphan Care Alliance. What do you hope to gain?

How many people are in your household (total number of children and adults)?

What is your average annual household income?

Please describe your need for financial assistance.

Please check the boxes to confirm you have read:

I acknowledge that anyone being awarded a scholarship will be expected to pay a co-pay

I acknowledge that anyone being awarded a scholarship will sign a contract committing to attending the program and arriving on time.

I have read and agree to the above terms and conditions. Please type full name.

Please provide below the names and contact information for 2 character references.

Character references need to include your name, how they know you and how long they have known you, along with any pertinent information we should know. Please have character references submit directly to Stacia Washausen, Administrative Director, in one of the following ways: 1. E-mail: stacia.washausen@orphancarealliance.org. 2. Mail: 115 N. Watterson Trail, Suite 201, Louisville, KY 40243 3. Fax: 502-515-3089

Consent Form

1. PURPOSE Community Impact Fund Application The undersigned agrees that this application is being made for the purpose of obtaining assistance with therapy, counseling or related services. The undersigned further acknowledges that the willingness to accept an application is not any type of acknowledgment or representation on behalf of Orphan Care Alliance that assistance will be granted or given. 2. AUTHORIZATION AND RELEASE The undersigned further authorizes any person included in the list of references to release to Orphan Care Alliance or its representatives personal information and opinions regarding eh applicant's lifestyle, language, habits, truthfulness, parental fitness, and general moral and biblical character. 3. LIMIT OF LIABILITY The undersigned acknowledges that Orphan Care Alliance has made no representation or warranty that financial aid or assistance will be furnished to the undersigned; and further acknowledges that Orphan Care Alliance shall have the sole discretion to accept or deny this application with or without cause. The undersigned further releases and holds Orphan Care Alliance harmless from any liability of any type or nature as a result of allowing the undersigned to submit this application. 4. SIGNATURES We are providing this information to Orphan Care Alliance for their internal and confidential use. All information contained in this application is accurate to the best of our knowledge.