PHP Family Scholarship Application Page - North Carolina Medical Society

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Family Scholarship Application

Application

ID Number

** Note: This is the NCPHP participant’s birthdate and Social Security number. You must provide this number to the Treatment Center or outpatient provider for processing of payment.

Birthdate: (MM/DD/YYYY)*

Last 4-digits of Social Security #:*

Section 2

Last year's gross household income:

Savings:

Current debts:

Mortgage debt:

Description of financial circumstances (please be as informative as possible):

Financial circumstances:

Please provide a description for use of the requested family funds:

Use of funds:

If the scholarship is to be used to facilitate therapy for a family members, please fill in the following information:

Family member name:

Treatment/Therapy provider:

Address:

Phone:

Contact name:

Date therapy begins:

(Must have firm therapy start date to qualify for scholarship.)

Section 3

By checking the box below, I declare, to the best of my knowledge and belief, that the above information is true, correct, and complete.

I agree.*

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