Scholarship Application

Music Therapy of the Ozarks Scholarship Application

contact@musictherapyoftheozarks.org

Date of Request

Date

Client Name

Date of Birth

Date

Age

Address

Phone

Email Address

example@example.com

Mother's Name

Occupation

Employer and Phone

Father's Name

Occupation

Employer and Phone

Are you currently receiving music therapy services?

If yes, name of music therapist

How many persons live in your household?

Names and ages of family members living in household

Music Therapy of the Ozarks Scholarship Application

All income should be reported as your monthly net income (AFTER TAXES AND OTHER DEDUCTIONS)

Father's monthly income after taxes and deductions

$

Mother's monthly income after taxes and deductions

$

Child support received monthly

$

Day received

Business income monthly after expenses

$

SSI monthly income

$

Day received

Child's monthly SSI income

$

Day received

Food stamp benefit amount

$

Day Received

Do you receive any other food assistance? Type "yes" or "no."

Do you receive utility assistance?

$

Do you receive housing assistance?

$

Other assistance received?

$

Other income received?

$

All assets should consist of an estimate of the value of the property or vehicles owned. Please include estimates of current balances on investment and savings accounts.

Do you own your home? Type "Yes" or "No"

Approximate value of home

$

Remaining loan statement

$

Please list any vehicles you own.

1.

2.

3.

Please list the approximate value of your owned vehicles.

1.

2.

3.

Please list your remaining loan amounts on these vehicles.

1.

2.

3.

Do you own any farm equipment, recreational vehicles, or recreational equipment?

YesNo

Value of Farm Equipment

$

Value of Recreational Vehicles/Equipment

$

Do you have any retirement plans through your employer? Type "yes" or "no."

Value of retirement

$

Penalty for removal

$

Do you have any IRA's or CD's? Type "yes" or "no"

Value of these investments

$

Penalty for removal

$

Do you own rental property? Type "yes" or "no"

Value of the property

$

Monthly income from property

$

Do you own any land/acreage? Type "yes" or "no"

If applicable, please type the amount of land and location.

Income earned from land

$

Do you own livestock? If yes, please indicate the type of livestock owned.

Value of livestock

$

Do you have a savings account? If yes, indicate banking institution.

Amount in savings

$

Do you have a checking account? If yes, indicate banking institution.

Amount in checking

$

Do you have cash on hand? If yes, indicate amount of cash in hand.

$

Do you have additional assets? If yes, please indicate what they are.

If applicable, indicate the value of your additional assets.

$

Monthly Expenses

Please estimate monthly expenses. If a payment is taken directly out of your paycheck then please do not list this as an expense in this section as it is already reflected in your income.

Rent/House payment after any assistance received

$

If trailer: monthly pad site cost

$

If rental property is owned, monthly payment:

$

If land/acreage owned, monthly payment:

$

Total of vehicle payment

$

Home phone

$

Cell phone

$

Child care after any assistance received

$

Child support paid if not already deducted from income

$

Utilities after assistance is deducted

$

Gas for vehicles

$

Cable/internet/satellite

$

Trash - specify monthly amount

$

Groceries - this is above any benefits received

$

Medical insurance cost if it is not already taken out of income

$

Renters Insurance

$

Car insurance for all vehicles

$

Life insurance on any member of the family

$

Other insurance

$

Below, please list any credit cards, medical expenses, student loans, and other loans.

If applicable, please indicate credit card #1 and it's type.

If applicable, please indicate the balance on credit card #1.

$

If applicable, please indicate the monthly payment on credit card #1.

$

If applicable, please indicate credit card #2 and it's type.

If applicable, please indicate the balance on credit card #2.

$

If applicable, please indicate the monthly payment on credit card #2.

$

If applicable, please indicate credit card #3 and it's type.

If applicable, please indicate the balance on credit card #3.

$

If applicable, please indicate the monthly payment on credit card #3.

$

If applicable, please indicate credit card #4 and it's type.

If applicable, please indicate the balance on credit card #4.

$

If applicable, please indicate the monthly payment on credit card #4.

$

If applicable, please list medical expense/bill #1 here as well as the name of the patient involved.

If applicable, please list the balance for medical expense/bill #1.

$

If applicable, please list the monthly payment for medical expense/bill #1.

$

If applicable, please list medical expense/bill #2 here as well as the name of the patient involved.

If applicable, please list the balance for medical expense/bill #2.

$

If applicable, please list the monthly payment for medical expense/bill #2.

$

If applicable, please list medical expense/bill #3 here as well as the name of the patient involved.

If applicable, please list the balance for medical expense/bill #3.

$

If applicable, please list the monthly payment for medical expense/bill #3.

$

If applicable, please list medical expense/bill #4 here as well as the name of the patient involved.

If applicable, please list the balance for medical expense/bill #4.

$

If applicable, please list the monthly payment for medical expense/bill #4.

$

If applicable, please indicate whether or not you have a student loan.

Has this loan been deferred? Type "yes" or "no."

What is the student loan for?

If applicable, please indicate the balance on the student loan.

$

If applicable, please indicate the monthly payment on the student loan.

$

Other loan: Please be specific as to what the loan is for.

If you listed an "other loan," please indicate which finance company it is through.

If you listed an "other loan," please indicate the balance on this loan.

$

If you listed an "other loan," please indicate the monthly payment on this loan.

$

Name of Individual filling out this form

Our Story:

Optional Publicity Release:

I agree to allow Music Therapy of the Ozarks to...

Use my child's photograph and/or personal story (type "yes" or "no.")

Use my family's photograph and/or personal story

If checked, I understand that this information may be used for publicity

purposes including television, radio, brochures, donor publications,

newspaper, magazine stories, fundraising events, educational purposes,

social media, and advertisements.

Electronic Signature: please type your name below if you agree with the statement above.

First NameLast Name

Date

FOR OFFICE USE ONLY

Received by

Verified by

Date

Approve

Amount Approved ( ____ sessions at $________ per session)

Amount Approved ( $___________ for 1 semester term of group sessions)

Disapprove(State Reason)

INCOME AND ASSETS

PLEASE PROVIDE PROOF OF INCOME (Check stub, tax return, bank statement, etc.)

INCOME AND ASSETS

*PLEASE PROVIDE PROOF OF INCOME (Check stub, tax return, bank statement, etc.)*

PLEASE PROVIDE PROOF OF INCOME (Check stub, tax return, bank statement, etc.)