Kiddos Clubhouse Foundation Scholarship
2010 SCHOLARSHIP APPLICATION
Who may apply?
A family applying for this scholarship must:
• Currently live in the state of Georgia
• Demonstrate the need for funds due to lack of insurance, lack of insurance coverage, lack of other funding sources
• Be applying for a child under the age of 21
• Not have received a scholarship from Kiddos’ Clubhouse Foundation within the past two (2) years
What is the amount of the scholarship?
The scholarships to be awarded will provide up to $2,500 for payment of therapeutic services or equipment payable directly to the clinic where your child has received the services, licensed therapist or business or the equipment vending company that supplies the equipment.
What is the process?
• Download the application, please print it out, fill it out and sign it. Go to www.kiddosclubhousefoundation.org to download application.
• Applications will NOT be considered in the order in which they are received. All applications will be considered at the same time.
• All applications must be postmarked by March 31st, 2010
• Completed applications may be mailed to:
Kiddos’ Clubhouse Foundation
ATTN: Scholarship Application Team
11539 Park Woods Circle, Suite 502
Alpharetta, GA 30005
• Please allow 60 days past deadline date for processing, review and decision
• All applicants will be notified in writing of the status of their application within 60 days past the deadline date
• All scholarship monies must be utilized for purposes stated within one year from notification date.
• Families must be back in contact with a representative of Kiddos’ Clubhouse Foundation within 2 weeks of notification of scholarship (notifications will occur via phone call, email and/or regular mail).
Guidelines
• The monies may NOT be used to pay insurance premiums or medical bills.
• All invoices for therapy services provided or therapy equipment must be submitted to Kiddos’ Clubhouse Foundation. Funds may not be used for previous outstanding balances and must be for services past scholarship award date.
• Applications will only be accepted by mail. Applications that are sent via email or fax will not be considered.
• Applications that are incomplete or received without all required documentation will not be considered.
Kiddos' Clubhouse Foundation makes every effort to remain objective during the process for determining the recipient of the scholarships; therefore the first two pages of this document which contain all personal identification information will be removed and the application will receive a number code. Throughout the rest of the determination process the application will be referred to only by the number code. It is essential for purposes of objectivity and confidentiality that in filling out the remainder of this application names or other identifying information be left out. This refers to all sections, including the therapists and doctor sections and their names.
HIPAA NOTICE: The United States Congress has enacted the Health Insurance Portability and Accountability Act (HIPAA), which took effect April 14th, 2003. HIPAA was designed to protect patient’s medical records and other health information provided to health plans, doctors, hospitals and other health care providers. We are required by applicable federal and state law to maintain the privacy of your medical information.
