The Stogie's Family Scholarship Application

The Stogie's Family Scholarship Application

At Vincent's Clubhouse, we believe everyone deserves the opportunity to learn, grow, and be part of a community where they are truly seen and valued. We are proud to offer programs that are intentionally affordable and accessible. However, we also recognize that many families supporting individuals with autism and other developmental disabilities face ongoing financial challenges, making even modest program fees difficult at times. The Stogie's Family Scholarship Program was created with this understanding and compassion at its core.
Member Information
Member Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Program Applying For
Requested Start Date

MonthDayYear
Date
Member Needs & Goals
Please describe how participation in this program will benefit the individual.
Commitment
Days Per Week Planning to Attend:
Are you able to commit to consistent attendance?
Please note: Vincent's Clubhouse programs are designed as full-time experiences, and weekly program fees reflect full-time enrollment. Consistent attenance is strongly encouraged to ensure participants receive the maximum benefit from services, build meaningful relationships, and make progress toward their goals.
Parent/Guardian Information
Parent/Guardian Full Name

First NameLast Name
Relationship to Member
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Full Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Household Information
Total Number of People in Household
Number of Dependents
Number of Individuals in Household with Disabilities
Financial Information
Total Household Annual Income
Public Assistance (check all that apply)

Other
If Other, please explain
Financial Hardship
Please describe any financial circumstances impacting your ability to pay for services.
Proof of Income
To help us accurately assess financial need, please provide ONE of the following:

Most recent federal tax return (first 2 pages only)

OR

Last 2 months of paystubs for household
Cancelof
Note: All documents are kept confidential and used soley for scholarship determination.

If you are unable to provide documentation, please contact us. We are committed to ensuring access and will work with families on a case-by-case basis.
Certification and Signature
I certify that the information provided is true and complete to the best of my knowledge.
Parent/Guardian Electronic Signature
Date

MonthDayYear
Date
Should be Empty:

The Stogie's Family Scholarship Application

Member Information

Commitment

Parent/Guardian Information

Household Information

Financial Information

Proof of Income

Certification and Signature