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Neurodevelopmental Scholarship Application
To apply for this program please complete the application below. Priority will be given to members who have been active with The FOUNDATION.
In order to receive a scholarship, you must first contact Kay Ness and be on her schedule.
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PARENT INFORMATION
First Name:
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Your answer
Last Name:
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Your answer
Address 1:
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Your answer
Address 2:
Your answer
City:
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Your answer
State:
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Choose
FL
Phone Number:
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Your answer
Email:
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Your answer
APPLICANT INFORMATION
Child's First Name:
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Your answer
Child's Last Name:
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Your answer
Age:
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Your answer
PROGRAM INFORMATION
Has your child been evaluated by a Neurodevelopmentalist (ND)?
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No, my child has never had an ND evaluation and I am requesting the initial eval ($625).
Yes, my child has been evaluated by an ND and I am requesting a follow-up appt ($475).
If you are requesting a follow-up appointment, please provide the date of your last eval.
Your answer
What are the areas you are most concerned about?
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Your answer
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I have attended a training/seminar by Kay Ness.
I have listened to Kay's "Audio Seminar' explaining the ND Program.
I have not attended training or listend to Kay's seminar..
If you have had a previous evaluation please answer the following questions.
In what ways has the program benefitted your child?
Your answer
What areas do you feel you need the most assistance with?
Your answer
How many days per week on average are you able to work on any part of your program plan?
Your answer
Which specific activities do you find easiest to implement?
Your answer
Do you have a therapist or tutor assisting you in implementing this program plan?
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Your answer
Scholarship Amount
Please let us know the scholarship amount required. Maximum amount for first visit is $325. Follow up
appointments can request any amount necessary for your family to participate. It is not guaranteed you
will receive the full amount requested. It is our goal to allow as many families as possible to participate
so we will do our best to accommodate every need. Please take into consideration if you can afford to
pay for a portion of your evaluation, that will allow another family the opportunity to participate.
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I do not need a scholarship.
I need a partial scholarship.
Requested scholarship amount:
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First time families maximum scholarship amount is $325. If you do not need a scholarship please enter $0.
Your answer
Other Information
Comments:
Your answer
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I am a member of The Foundation.
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