PCO Hope Case Manager/House Manager Form

Case Manager / House Manager Scholarship Applicant Referral Form

The PCO Hope Memorial Scholarship program assists individuals who are transitioning from inpatient treatment to sober living. Scholarship funds provide short term rental assistance to allow individuals time to settle into their sober living home and find employment. Additionally, once settled into sober living we can provide our transitional benefits program where individuals are eligible to receive benefits at the 30, 60 and 90 day points after they have received their initial scholarship. Each benefit requires it's own individual application.
All applicants must have a primary residence within Plymouth County.

The case manager / house manager scholarship applicant referral form must accompany all applications for scholarships and transitional benefits in order for the applications to be reviewed.

Please fill out this form completely so we have a full understanding of your needs.

A member from our Board of Directors will be in touch with you should there be any additional questions or information needed.
Individual is applying for: *

Scholarship Transitional Benefits
TRANSITIONAL BENEFITS APPLICANTS

30, 60 and 90 days after receiving a PCO Hope Scholarship, individuals are eligible for additional benefits through our Transitional Benefits program. These funds require their own application for each time funds are requested.
Date of Request: *

Month Day Year
Date
Name of Individual Receiving Funds: *

First Name Last Name
Your Name: *

First Name Last Name
Your Organization: *
Please enter the name of your treatment facility or sober home
Your Email: *
example@example.com
Phone Number *
Enter the best number for us to reach you at
Address of Facility: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What is the best way for us to contact you? *

Phone Email
What do you feel makes this individual a candidate for a scholarship? *
Why you feel this individual should receive a scholarship. 500 words or less
Completing this application does not guarantee a scholarship. Please give up to 7 business days for a response. Applications will only be considered for residents of Plymouth County. Maximum scholarship award is $500.
Your signature: *

Clear
Should be Empty:

Case Manager / House Manager Scholarship Applicant Referral Form