Brighter Together Scholarship Application Form

Shining Star Scholarship Application

Brighter Together, Inc. offers a Scholarship Program to help families in Idaho access essential therapy services for their children. Eligibility is based on household income, family size, and demonstrated financial need. Awards are determined using the Federal Poverty Guidelines to ensure equitable support.Brighter Together, Inc. is committed to inclusivity and does not discriminate based on age, gender, race, sexual orientation, gender identity or expression, creed, religion, disability, or national origin. Our goal is to ensure that children in Idaho can receive the therapy services they need, regardless of financial circumstances.
Child's Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date

Family Information
Parent 1
Parent Name*

First NameLast Name
Home Phone*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2
Parent Name

First NameLast Name
Home Phone
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other children in family
Configurable list*
If you have other children currently receiving therapy (with us or elsewhere), feel free to share below. This helps our team understand your family’s total therapy needs and financial considerations.

Family Income Information
We know it can feel personal to share financial information. We only ask because this helps our nonprofit make timely, informed decisions that align with our board policies, funding guidelines, and bylaws.
Monthly Income for Your Whole Family (before taxes are taken out)*
$

Additional Income

	Income ($)
Government Assistance
Child Support
Social Security
Income From 2nd Job
Other
Empowering Parents Grant
Total Additional Income

Total Monthly Income (before taxes are taken out)*

Therapy Needs & Cost Breakdown
What type of therapy or support are you seeking financial assistance for? (Check all that apply)*

Speech therapyOccupational therapyPhysical therapyFeeding therapySocial skills groupsOther
How much does each therapy session cost you out-of-pocket? (This means the amount you pay after insurance is billed, such as your copay, coinsurance, or full rate if not covered.)*
$
How many sessions per week do you expect to attend?*
Please explain the program you are seeking assistance for and reasons for need. *
(For example: insurance doesn’t cover enough sessions, high out-of-pocket costs, denied coverage, no insurance, not eligible for Medicaid, etc.)
Scholarship Amount Requested*
$ 💡 Note: We typically award scholarships up to $500. Families may apply for one additional $500 scholarship later in the year, if needed. Please request no more than $500 at this time.
Are you working toward meeting an insurance deductible or facing other specific out-of-pocket costs?*

YesNo
If yes, please briefly explain:
Please share any other financial factors or special circumstances that would help us understand your request.

Family Agreement
If awarded a scholarship from Brighter Together, you will be notified in writing. Scholarships are awarded based on family size, income, and alignment with our mission to support families who fall in the gap — those who do not qualify for Medicaid and whose insurance provides limited or no coverage for therapy services.

Brighter Together is a nonprofit organization with its own independent board. While it is closely connected to the values and mission of Better Together, it operates as a separate entity. Scholarship recipients are free to use awarded funds at Better Together or any other qualified therapy provider of their choice.

Scholarships are currently offered in amounts of up to $500 per application, with the option to reapply for one additional $500 scholarship later in the same calendar year.

This financial assistance is designed to reduce the burden of out-of-pocket therapy expenses. Brighter Together does not pay therapy providers directly. Instead, families are responsible for arranging payment with their provider using scholarship funds as needed.

By signing below, you acknowledge and agree to the following:
- The information provided in this application is accurate and truthful.
- Providing false or misleading information may result in the withdrawal of scholarship support.
- You are responsible for paying your therapy provider. Brighter Together is offering scholarship support only and is not involved in direct billing or treatment.
- Any remaining balance after insurance and/or scholarship funds is your responsibility, unless otherwise arranged with your provider.
- Scholarships are limited in availability and not guaranteed beyond the approved award.
Signature

Clear
Should be Empty:

Shining Star Scholarship Application

Family Information

Family Income Information

Insurance Eligibility (Including Medicaid / Katie Beckett)

Therapy Needs & Cost Breakdown

Family Agreement