Application for 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 seeking advocacy support. 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 a committee made up of the Executive Vice President of Therapy Services, Chief Development Officer, Accounting Manager, Vice President of Education, Pediatric Clinic Manager and the Special Education Support Services Manager.

Parent Full Name *

Email *

Cell Phone *

Address *

City *

State *

Zip Code *

What is your annual household income? *

How many members reside in your household? *

Name of Children, Ages in household and diagnosis (if applicable) *

Total Monthly Income *

Total Monthly Income from Job *

Total Monthly Income from SSI: *

Totaly Monthly Income from TANF *

Total Monthly Income from SNAP *

Total Monthly Income from Social Security *

Total Monthly Income from Child Support *

Other Income *

Total Monthly Expenses *

Monthly Housing Expense *

Monthly Utilities Expense *

Phone (cell, home) and Cable Expense *

Car Payment Expense *

Child Care Expense *

Monthly Credit Card Payment (s) *

Monthly Insurance Payment (car, health, etc.) *

Loan Payments *

Outstanding Medical Payments *

Other Expenses *

I receive childcare subsidies (CCS). *

Yes

My CCS co-pay is $ *

In a few sentences, please tell us why it is important for your child to receive Special Education Support Services (advocacy) and how receiving scholarship 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.

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.

I understand that any information obtained is protected under federal and State confidentiality laws and regulations and cannot be disclosed without written consent unless otherwise provided for the laws and regulations. I also understand that I may revoke (cancel) this consent at any time, except to the extent that action has been taken in reliance on it, and that this consent automatically expires when the financial assistance grant expires.

Acknowledgment

Parent / Guardian Signature

Clear

Printed Name(s)

Today's Date