Scholarship Application Question Title * 1. Contact Information Full Name * Address * Address 2 * City/Town * State/Province * ZIP/Postal Code Email Address Phone Number * Question Title * 2. Date Of Birth Question Title * 3. What is your current living situation? (ex. with parents, shelter, in your own home) Question Title * 4. What is your drug(s) of choice? Question Title * 5. Have you tried treatment before? If so where and what were the outcomes. Question Title * 6. Which type of Scholarship(s) are you in need of? Housing Costs Counseling Costs Recovery Coaching Food Costs Question Title * 7. Why do you have a need for financial assistance? Question Title * 8. Are you willing to relocate for up to a 6 month period or longer? Question Title * 9. Do you currently have any outstanding legal issues? Please include any outstanding warrants and any past/current/pending charges, upcoming court dates, etc. Question Title * 10. Do you have any special circumstances that we should consider? Question Title * 11. In a short paragraph please tell us why you should receive a Scholarship. Question Title * 12. Your Insurance Provider name Question Title * 13. Policy Holder's full name Question Title * 14. Policy Holder's date of birth Question Title * 15. Insurance Provider phone number Question Title * 16. Member Number Question Title * 17. Group Number Question Title * 18. HMO or PPO Done