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Scholarship Application

Program Scholarship Guidelines:
• Applicants are evaluated without regard to race, religion, natural origin, sex or ability.
• Funding is limited and scholarships are not guaranteed to all applicants.
• Staff of LEAD with Horses and their children are not eligible for scholarship assistance.
• Incomplete applications will not be reviewed.
• Scholarships will be awarded based on qualifying circumstances.

Program Request *

I am interested in/attending:

Private therapy services

Group educational programs

Client Information

Client's Name *

First Name

Last Name

Date of Birth *

(mm/dd/yyyy)

Grade (if attending school)

Scholarship Category *

Check all that apply and submit any supporting documentation (end of form)

Financial need

Veteran/Military/First Responder

Foster or adoptive

Special circumstances

Please explain

Contact Information

Name of person completing this form *

First Name

Last Name

Relationship to client *

Address *

Address Line 1

Address Line 2

City

State

State/Province

ZIP/Postal Code

Phone *

Email *

Verify Email *

Income/Household

Income *

Please list your total household income from all sources (including wages, investments, child support social security, public assistance etc)

How many children currently live in the household? *

Please list their ages *

Are any other family members applying for scholarships or assistance from LEAD with Horses? *

Yes

Has anyone in your household previously received financial assistance from LEAD with Horses? *

Yes

Name of other applicant

Name of recipient

Amount you can potentially contribute *

What do you hope you/your child will gain from this experience? *

Supporting Documents

Please black out social security and id numbers

Tax return or wage statement

Black out social security numbers

Proof of veteran status

Copy of ID, discharge papers, or other records indicating military service. Black out ss or id #s.

Proof of foster or adoptive status