Brighton Center's

Financial Assistance Application

Brighton Center seeks funding from grants, foundations and individual contributors to establish the financial assistance program for Brighton families. Funds will be available for families with children who are enrolled in Brighton’s Preschool, receiving therapy in the Pediatric Therapy Clinic and who are enrolled in the Special Education Support Services Program.

The Pediatric Therapy Clinic uses the financial assistance for families who qualify as low income based on federal poverty guidelines, have high deductibles and/or copays, or families who do not have medical insurance coverage. Assistance will be determined by an internal committee.

Financial assistance is awarded for a maximum of 4 months, depending on availability of funds, qualifications, and need.

Parent / Guardian Full Name *

Email *

Cell Phone *

Address *

City *

State *

Zip code *

We are applying for financial aid for the following Brighton Center Programs *

Pediatric Therapy Clinic

Preschool - Higgins Campus

Preschool - Lullwood Campus

Special Education Support Services

Household Information

Are you a foster family? *

Yes

How many members reside in your household?

Child First Name *

Child Last Name *

Child Date of Birth *

Does your child have a disability or delay? *

Yes

Child 2 First Name

Child 2 Last Name

Child 2 Date of Birth

Does Child 2 have a disability or delay

Yes

Are any of your children currently enrolled in any Brighton Programs? *

Household Income
(Parent(s), Guardian, Dependant)

Gross Monthly Income *

Total Monthly Income from Wages, Salaries, Tips *

Monthly Self-employment Income

Monthly Unemployment Benefits

Totaly Monthly Income from TANF *

Total Monthly Income from SNAP *

Total Monthly Income from Social Security *

Total Monthly Income from SSI: *

Total Monthly Income from Child Support *

Other Income *

Other Income for Child *

Household Expenses
(Parent(s), Guardian, Dependant)

Monthly Housing Expense

Monthly Utilities Expense

Monthly Phone (cell, home) and Cable

Monthly Medical or dental expenses not covered by insurance

Co-pays, co-insurance, & deductibles

Monthly Medication, medical supplies, diagnostic devices, etc.

Medical & dental insurance premiums for family

Medical or dental debt that is being paid on an established payment plan

Child Care and Respite Expenses

Costs & fees associated with the adoption of a child

Monthly Credit Card Payment (s)

Court-ordered child support payments for children who were not counted in household in calculating the adjusted income

Monthly Insurance Payment (car, pet, etc.)

Loan Payments

Car Loan Expense

Total Monthly Expenses

Other Expenses

Credits

I receive childcare subsidies (CCS). *

Yes

Why Brighton Center

In a few sentences, please tell us why it is important for your child to receive Brighton Center Services and how receiving financial assistance will benefit your family:

Letter of Agreement

I understand and accept the financial assistance granted to me and my family. I also understand and agree to the following:

I agree to take full responsibility for any tuition payments, copays or payments not covered by the financial assistance or any other entity.
I understand that upon termination of this agreement, I will be solely responsible for payment for my child(ren).
I understand that implementation and continuation of the financial assistance is based on availability and continuance of funding.
I agree to the Financial Assistance schedule and understand that after the scheduled funds have expire, I will need to reapply for Brighton’s Financial Assistance program, and I may or may not qualify for another assistance term. Schedule to be provided after application has been received and the Committee has reviewed all documents and available funds.
I understand that my application or acceptance in the financial assistance program may be revoked at any time due to noncompliance of the agreed upon terms of this contract or funds are not available.
I agree that all the information provided is true and correct. I understand this is only an application and there is no guarantee that I will qualify for the tuition assistance program. I also make a commitment to provide any information required and abide by any other requirements to qualify for the tuition assistance.

I give permission to Brighton Center to share with funders how the financial assistance is helping my family. Brighton Center can disclose the following information: *

my child's first name only

a picture of my child

a brief description of how my child is developing and making progress

I further acknowledge that the information to be released was fully explained to me and that is consent is given of my own free will.

Acknowledgement

Parent Signature *

Clear

Printed Name *

Today's Date *