Wild Hearts

Scholarship Application

Completing this form creates an opportunity to apply for financial consideration.

Please submit the Wile Hearts Interest Form before submitting the Wild Hearts Scholarship Application.

Qualification can be further discussed during the Admissions portion of the registration 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.

Our Sliding Scale

This Sliding Scale is available to all Wild Hearts program participants. Grant funding and private donation sources support the organization to offset the fees clients are unable to pay. A reduced rate on this scale will not be offered to clients who have the financial means to pay full fee for services. The income levels associated with the percentage of poverty level shown in the document are directly correlated with the federal department of the Health and Human Services, as published by aspe.hhs.gov, the official government website of the ASPE, the Office of the Assistant Secretary for Planning and Evaluation. Clients who request to pay according to sliding scale will be asked to provide 1) the total number of people living in the household and 2) the total household income.

View Sliding Scale

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

Household Income

What is your total household income?

Household Size

How many people are living in your household?

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 Wild Hearts program, do you agree to be interviewed and to provide written or video testimonial of your experience without compensation?

Yes

GUIDELINES

If further information is needed, this may be requested during the Admissions process. Financial need requests are open to anyone for whom attending the Wilderness4Life program would pose a financial hardship. Financial need recipients are responsible for securing their own travel to and from the Wilderness4Life program sessions.

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.