Name of Participant
Date of Birth
TABS# (OPWDD)
Diagnosis
MSC (Medicaid Service Coordinator)
MSC Ph #:
Participant's Contact:
Home Ph#
Email::
County:
Preferred Stable:
Type of Equine Assisted Activity:
Cell Ph#
Therapist Name & Contact
Participant Related to Veteran?
Additional Expenses? (therapeutic, medical)
If Yes, How much/annually?
Does your child have other sources for equine therapy?
Scholarship Criteria and Disclaimer
STAT, Inc., is a 501(c)3 non-profit public charity. Facility use fees are necessary to help defray the expenses of providing equine assisted activities and cover a portion of the actual cost. A scholarship fund is available to assist riders who could not otherwise afford to participate. Scholarship funds are limited and we have hundreds of requests for assistance.
Fundraisers, grants in aid, and direct donations are the lifeblood of STAT which provides us with the opportunity to help many families and improve the lives of many children with special needs and at risk youth. We ask that with an approved scholarship (i.e., vouchers issued) that you support STAT throughout the year in some way (i.e., sell raffle tickets, assist at a fundraiser)
In accordance with our organization Bylaws and Policies: by accepting any scholarship and in participating in STAT programs, I am agreeing to adhere to any and all facility and program rules or guidelines. This document also releases STAT, Inc. (including but not limited to: manager, directors, officers, volunteers, and agents), other sponsoring organizations, and any other parties connected with events, either singly or collectively, from any liability for an injury, harm, loss, inconvenience, or damage suffered or sustained as a result of participation in one or more events or any activities associated therewith.
In submitting this form, I also give permission to STAT, Inc., to use photographs or portions thereof, whether still or moving, voice and likeness for trade, publicity or for any other lawful manner whatsoever; hereby waiving my right to review such photographs, etc., prior to use
Submit button is in essence a Digital Signature of Applicant/Parent/Guardian
Mother's (or Guardian) Name:
Father's (Other) Name:
DATE OF APPLICATION
2012 Online Scholarship Application
Is your child non-verbal or minimally verbal?
Does your child own an AAC device?
