Westminster Homes of the Lehigh Valley: Scholarship Application.

This form must be filled out by a recovery professional. Westminster Homes of the Lehigh Valley accepts scholarship applications from any individuals struggling with the disease of addiction, who have a desire to further their recovery in a qualified recovery residence. All recovery residences must be approved by our Board. Only candidates with a strong desire to continue their recovery will be considered. If approved, money will be paid directly to the recovery residence.

Professionals Name Last Name Phone Number Email

Date

Professionals Qualifications:__________________________________________________

Professionals are required to submit a paragraph detailing why they believe this candidate can be successful.

Professionals Signature

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Candidates Information: First Name Last Name Phone Number Email

Candidates primary drug of choice:__________________________________________________________
is the candidate currently on MAT?
Has the Candidate been to any treatment facilities?
If candidate is approved for a scholarship, when will the funds be required?   Date
Contact Information for Recovery Residence:   Name of facility:      Email      Phone Number   House Managers name.         House Managers contact: Phone Number   Email

Has the candidate received any other scholarships in the past 6 months? (If yes, please explain).

Candidate is required to provide a compelling paragraph on why their scholarship request should be considered. Only candidates with a sincere desire to continue their recovery, and a willingness to engage in a sober community will be considered.

Signature. By signing this form, I attest that the information I have given is true and correct. If approved for a scholarship, I also agree to allow Westminster Homes of the Lehigh Valley board members to contact me to follow up on my recovery status on a weekly basis. Your anonymity will always be respected. We use your recovery information in order to analyze how our program is working. This helps us qualify for funding from other organizations.

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