Lemon City Collective Scholarship Application
We are passionate about ensuring all children have access to great developmental services. In order for us to provide financial assistance to your family, please fill out the information below. 

By filling out this form, you give permission to Lemon City Collective, Inc. to collect your/your child's information. This information will remain confidential and will not be distributed to any third parties without your consent.
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Email *
Child's Name *
Child's Date of Birth *
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DD
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Parent/Guardian Name *
Parent/Guardian Relationship *
Phone Number *
Address *
Does your child have a medical diagnosis? (please explain below) *
Name of child's primary care provider:  *
Therapies your child currently receives:  *
Required
Therapies your child needs: *
Required
Your household's estimated annual income:  *
Your household size: *
Does your child have health insurance? if so, what insurance provider? *
Does anyone in your household receive any of the following social services?  *
Required
Please explain:  *
What would be an affordable per session rate for therapy services for your child?  *
Is there anything else you would like to share? 
Disclosure: Lemon City Collective, Inc. is a 501(c)3 charitable organization. In an effort to make our services accessible, we engage in fundraising efforts to provide case-by-case financial assistance when possible. By completing this form, you acknowledge that this application does not guarantee that you or anyone in your household will receive services or financial assistance from Lemon City Collective, Inc. We review applications in good faith, and expect that the answers provided above are truthful. Financial assistance is awarded based on need as well as the funding currently available to the organization. Should your household qualify for financial assistance, we cannot guarantee that services will be provided. Lemon City Collective, Inc. reserves the right to discontinue services, change the level of assistance, or discontinue financial assistance at the organization's discretion. 

By checking the box below, you acknowledge the disclosure above, and declare that the information above is truthful and provided in good faith. 
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Type Your Name:  *
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