Einstein Mission Scholarship Application

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Email *

Full Name: *

Phone Number: *

Age of patient seeking treatment: *

Seeking scholarship for: *

Please be aware that at this time demand for care exceeds the Einstein Mission's current resources. Please understand all persons submitting an application are placed on a waitlist. When an opening is available, the next appropriate person is contacted. Once contacted by Einstein Mission that you are the next eligible applicant for an opening in care, you can submit documents demonstrating need. Additional inquiries after submission will not speed the process along. Multiple submissions and/or inquiries may result in processing delays. Please understand we are doing the best we can with the resources we have at this time. We will contact you when you are the next eligible applicant. We do look forward to connecting with you when we can appropriately provide care! Please indicate your understanding of this process below. *

I understand the above process.

I am challenged with... *

I am able to demonstrate need in the form of tax returns. I cannot otherwise afford treatment. *

Yes

I can provide proof that I fall 200% (0-199%) or more below the Federal Poverty Line.

Link to Calculator- FPL Calculator (2023) | PovertyLevelCalculator.com

Yes

Answering "no" to the above question does not disqualify you from care. At what percentage level do you fall? How can you additionally demonstrate need? *

I understand that while medical treatment may be offered at no cost, I will still need to pay for lab tests and medications, make lifestyle changes, and potentially change my current living environment to get better. On a scale of 1 (interested but would prefer a pill to fix the problem) to 10 (will do whatever it takes), where are you in your healing journey? *

Please explain your numeric choice from above in further detail:

Once you are feeling well, would you be willing to "pay it forward" by supporting someone on a similar journey? *

Yes

Send me a copy of my responses.

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