Wilderness Therapy

Scholarship Application

We're eager to assist those in need. Please visit one of the organizations listed on our partners page. If you live in Oregon or Washington, we may be able to help.

Complete and submit the form below to apply for a financial grant. If you live in a state other than Oregon or Washington, we still encourage you to visit one of our program partners.

While completing an application does not guarantee a grant, it does create an opportunity for consideration.

Qualification can be further discussed during the interview portion of the application process.

This online form is available for your convenience. Please be aware that providing information to us, electronically, verbally, or by mail can involve some risk. While we do our best to maintain the confidentiality of information you provide, some things are beyond our control.

APPLICANT INFORMATION

Name of Applicant

First Name

Last Name

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Applicant's Date of Birth

YYYY

GUARDIAN INFORMATION

Name of Guardian

First Name

Last Name

Guardian's email address

Address (If different than above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian's phone number

(###)

###

####

Guardian's Date of Birth

YYYY

GRANT AMOUNT

Dollar Amount Requested ($)

Insurance Company Name

Insurance Benefits Available

Insurance Phone Number

(###)

###

####

RESOURCES/OBLIGATIONS

Family Funds Available ($ Amount)

Family Loans ($ Amount)

Investments ($ Amount)

Retirement Accounts ($ Amount)

Life Insurance Cash Value ($ Amount)

Other Assistance

Total Available

Your Home

Rent

Own

Mortgage

Mortgage/Rent Amount

Home Value

Mortgage Balance

GUARDIAN EMPLOYMENT INFORMATION

Please describe your employment situation.

Please describe any special circumstances.

COMPLETE YOUR APPLICATION

By signing this application, you state that you have read this application thoroughly and certify that to the best of your knowledge all of the information is correct and release PBJF and those associated of any liability associated with the information you provide. You also confirm that you understand that funding can be denied if the application is incomplete or if the information is found to be misleading. You further recognize the importance of your personal involvement in the program and commit yourself to do whatever may be required in order for this to be a successful experience for all those involved. By signing this application, you grant PBJF and individuals associated to discuss details about you and your child with our partner programs in regard to course of care and your financial obligations.

Certification of Correct Information and Release of Liability (Type your full name below)

With the intention to provide helpful information and feedback to other families and their children in-crisis, it is very important to share our experiences with each other. Upon completion of a partnering wilderness therapy program, do you agree to be interviewed and to provide written or video testimonial of my wilderness experience without compensation?

Yes

ADDITIONAL INFORMATION NEEDED FOR APPLICATION

**Additional REQUIRED information is used to determine eligibility. This includes: Two (2) most recent years of COMPLETE income tax returns and related tax schedules Two (2) most recent W-2's for father and mother, or legal guardian Personal Financial Statement that includes all assets and their values such as second homes and rental properties. Most recent Property Tax Statement (current year / most recent) Home Mortgage Statement or most recent House Rental Agreement Most recent Investment/ Brokerage Account statements ***Please remember to black out a portion of your social security numbers*** Email copies to: info@pbjwilderness4life.org Please enter "PBJF Grant Application Supporting Documents" in the subject field of your email. *While net income limit is $100,000, indebtedness and other factors are also considered— including outstanding loans and their values. Grants are provided based on the availability of funds and additional criteria as defined by our foundation board. The Parker Bounds Johnson Foundation does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations.

GUIDELINES

Application Guidelines Oregon and Washington residents only. Applications are reviewed on a rolling basis. Applicants will be notified as soon as a decision is reached. We provide partial grants only. Grant offer is good for 30 days following award notice. After 30 days, the grant offer will expire and applicant will need to re-apply. Grant recipients must notify us if they experience a change in financial status and no longer are in need of the grant. Grants are non-transferable. Grant recipients must notify us if they decide to not accept the scholarship. If further information is needed, a phone interview may be requested. Grant requests are open to anyone for whom attending a partner wilderness program would pose a financial hardship. Grant recipients are responsible for securing their own travel to and from the selected wilderness program. Approved Grant Recipients: With the intention to provide helpful information and feedback to other families and their children in-crisis, it is very important to share our experiences with each other. Upon completion of a partnering wilderness therapy program, participants and their parents or guardians agree to be interviewed, and to provide written or video testimonial of their wilderness experience. Anonymity is respected if requested. Application Checklist Is the Application form complete? Have you gathered all supplementary material (tax returns, W-2's, check stubs, etc)? Have you time available for the telephone interview?