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  • Estimated completion time: 10–15 minutes. Scholarship applications may take a few additional minutes

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  • Format: (000) 000-0000.
  • Preferred way to contact you:*
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  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Is the youth’s home address the same as the parent/guardian address listed above?*
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  • What are your youth’s strengths? Select all that apply.*
  • Are there any areas where your youth may need additional support? Select all that apply.*
  • What usually helps your youth when they become frustrated, upset or overwhelmed?Select all that apply.*
  • What does your youth enjoy doing? Select all that apply.*
  • Does your youth have any accommodations or support needs that would help them successfully participate in Skills Lab?*
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  • Format: (000) 000-0000.
  • Is this person authorized to pick up youth?*
  • Format: (000) 000-0000.
  • Is this person authorized to pick up youth?*
  • May your youth leave Skills Lab independently at dismissal?*
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  • Skills Lab membership is $150 per month and includes Saturday sessions, snacks, projects, materials, mindset coaching and career exposure.

     

  • Would you like your youth to be considered for scholarship assistance?*
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  • 1. Does the youth currently have active Maryland Medical Assistance (Medicaid)?*
  • 2. Does the youth currently experience one or more of the following? Select all that apply.*
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  • Youth's Medicaid/MCO*
  • Is the coverage currently active?*
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  • Tell Us About Your Youth's Current Support

  • Does your youth currently have a therapist, psychiatrist or other licensed mental health professional?*
  • Format: (000) 000-0000.
  • May UpSkill or its program partner contact this provider regarding the referral process?*

  • Initial Assessment Required
    No therapist? That’s okay.

    To complete the scholarship eligibility process, your youth will need an initial assessment with a licensed mental health professional.

    A therapist will contact you using the information provided in this application to discuss the assessment and schedule an appointment.

     

  • Do you agree to be contacted by a therapist to schedule an initial assessment?*

  • SKILLS LAB IS STILL AN OPTION!

    Your responses indicate that your youth may not currently meet the requirements for scholarship-funded enrollment.

    But they can still participate in Skills Lab for $150/month.

    Then:

    How would you like to continue?

    ○ Continue my registration at $150/month
    ○ Go back and review my scholarship eligibility answers
    ○ I'm not ready to enroll right now

    If they choose $150/month, send them directly to Step 8 and complete the normal registration

  • GREAT NEWS — YOU MAY QUALIFY!

    Based on your responses, your youth may meet the initial requirements for scholarship assistance.

    This initial screening does not guarantee scholarship approval. Final eligibility is determined after documentation review and intake.

  • How would you like to continue?*
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