Therapy Scholarship Application

*for individuals with Down Syndrome only

First name

Last name

Email

Phone

Parent Contact Information

Multi-line address

Country/Region

Address

City

Zip / Postal code

Treatment Center/Licensed Therapist

FInancial Statement/Health Insurance

Statement detailing the need for financial assistance. Please include health insurance and co-pay information.

Therapy Plan

Brief description documenting the type and course of therapy that will be conducted and how many sessions are anticipated. Please estimate the total therapy cost per session that will be paid out of pocket.

Therapy Scholarship Application

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