The Mary Shands Scholarship Fund
Application for Financial Assistance
SECTION 1: General Information
Date of Birth
Prefer not to say
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Home Phone Number
Mobile Phone Number
1a. How many people reside in your household (including yourself)?
1b. If your answer to the above question was more than 1, please explain further (listing each person, their relationship to you, and their age at the time of this submission.)
2. How did you first hear about the Mary Shands Scholarship Fund?
3. Should you receive financial assistance, would you be willing to provide a testimonial of your care?
SECTION 2: Current and Ongoing Conditions
4. Please describe your current and ongoing problems, in addition to your main health concern/diagnosis, in order of priority.
5. Please upload a list of your current medications and supplements, including vitamins, minerals, herbs, and homeopathic remedies. Please be sure to include the following information: Name of Medication/Supplement, Brand, Dose, Frequency, Start Date month/year, and reason for use.
Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png
If you would prefer to type your response, please do so in the box below.
6a. Have you made any changes in your eating habits because of your health?
6b. If your answer to the above question was YES, please describe and include information about any special diet or nutritional program you may follow. If your answer to the above question was NO, please enter N/A in the space provided.
7. Have you had any of the following dental procedures? Please select all that apply.
Metal amalgam fillings
Other (please describe in the space below.)
List other dental procedures (not including cleanings)
8. Describe your mental and emotional health. Please include any relevant treatment and/or practices that contribute to your mental and emotional wellness, including but not limited to therapy, meditation, attending church, and mind/body/spirit therapies. (Optional)
9. Are you currently or have you recently experienced a significant life event? If yes, please include any life events that feel significant to you, including but not limited to changes in your relationship, family, work, financial status, dietary or stress levels. (Optional)
10. What do you hope to gain by receiving bioregulatory medical treatment? What are your post-treatment health care plans?
11. What do you feel is your life's purpose?
SECTION 3: Treatment History & Recommendations
12. Please provide detailed information about your CURRENT treatment plan, including the full name of the person administering the treatment (with medical title), role (nutritionist, etc.), contact information (telephone and/or email), and the length of time that you have been receiving the treatment. Please provide this information for EACH TREATMENT you list.
13. Please provide detailed information about your PAST treatment plan, including the full name of the person administering the treatment (with medical title), contact information (telephone and/or email), and the length of time that you received the treatment, and the reason why you stopped the treatment. Please provide this information for EACH TREATMENT you list.
14. Please upload a letter written by your practitioner for which you are applying for financial assistance, detailing your treatment plan and approximate cost. Applicants must currently be an accepted patient of the practitioner/center for which you are applying for financial aid. All monetary aid provided by the Mary Shands Scholarship Fund shall be paid directly to the practitioner/center.
Section 4: Financial Information
15a. Please complete the financial information grid below. If a question is not applicable, please enter 0 in the space provided.
Co-Applicant (if applicable)
Combined Monthly Income (Applicant + Co-Applicant)
Monthly Income Source(s)
TOTAL HOUSEHOLD INCOME
15b. Upload your most recently submitted tax return or tax transcript from the IRS (please black-out the social security number on this transcript for security purposes.) If you would prefer to send via postal mail, please send to: Cheryl Radford Marion Institute 202 Spring Street Marion, MA 02738
Accepted file types: pdf, doc, docx, jpg, jpeg, png
16. Name of Health Insurance (if applicable). If more than one, please list both primary and secondary.
17. Please describe your employment. (Include your occupation, the number of hours per week you work, your salary or hourly wage, and how long you have worked there.) Students please note the name of your school (or if you are home-schooled), what your grade/year is, and whether you are enrolled full time, part time or are on any type of leave of absence.
18. If you do not have monthly income, please explain how you take care of your monthly expenses. If you do have a monthly income, please enter N/A in the space below.
19. Please use this space to tell us anything else that you feel we should know.
Authorization for Use or Release of Information
I (TYPE NAME IN SPACE BELOW) hereby authorize the use or disclosure of my individually identifiable health information (“Protected Health Information”) by the Marion Institute, Inc., (Mary Shands Scholarship Fund) a non-profit organization, to make determinations for financial assistance and need. I understand that my Protected Health Information may be subject to re-disclosure by The Marion Institute, Inc. pursuant to this authorization. I understand that The Marion Institute, Inc. will not use my Protected Health Information for any reason other than that which is stated above without my further authorization. I understand that I may revoke this authorization at any time by notifying the Marion Institute Inc. in writing, but if I do, it will not have an effect on any actions The Marion Institute, Inc. took before it received the revocation of this authorization.
TYPE FULL NAME HERE
By checking this box, the Marion Institute can follow up with me at periodic intervals to access private health care information, if necessary.
By checking this box, I agree to respond to follow-up questionnaires in a timely manner. If I do not comply with the questionnaires, the Marion Institute reserves the right to request that any and all funds that have been awarded to me be returned from the agreed medical facility. At that time, I will be held responsible for all costs that I have incurred up until that point.
By checking this box, I agree to keep confidential the amount that may be awarded to me as part of this scholarship program.
Signature of Individual or Individual's Representative
Type name of Individual's Representative (if applicable)
Relationship to the individual (if applicable)
Date of Birth
Date of submission
Signature Page to Application
I hereby certify that all information and attachments are true to my knowledge. I understand that false information may disqualify me from consideration for this award.
Type name below
Date of submission
Checklist for completed Mary Shands Scholarship Fund Financial Assistance Request Form:
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