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Therapy Scholarship Application

*for individuals with Down Syndrome only

First name*

Last name*

Email*

Phone*

Parent Contact Information*

Country/Region*

Address*

City*

Zip / Postal code*

Treatment Center/Licensed Therapist

FInancial Statement/Health Insurance*

Statement detailing the need for financial assistance. Please include health insurance and co-pay information.

Therapy Plan*

Brief description documenting the type and course of therapy that will be conducted and how many sessions are anticipated. Please estimate the total therapy cost per session that will be paid out of pocket.

Down Syndrome Foundation of Tallahassee

850-443-1822

downsyndromefoundationtally@gmail.com

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