Scholarship Application Form

The Rebuild Project

Client Information

Full Name

Phone Number

Email

Case Manager Information (if applicable)

Case Manager's Name

Phone Number

Treatment Facility Name

Client Circumstances

Circumstances

Assistance Requested: (Check one)

Other Assistance

Scholarship Requirements: Please make sure you meet the below requirements before submitting.

Certification and Signature
I certify that the information provided above is true and complete to the best of my knowledge.

Print Name

Date

Sign Below