Escape to Reality Foundation Scholarship Application
Revised 5 August 2011
1. There is
an ongoing deadline for scholarships; however, they will be available only as
funds permit.
2. Please
ensure you meet the eligibility requirements before applying and that you
include all of the supporting documents that are specified, failure to do so
will result in a termination of your application.
3. If any question does not apply to you in this
application please put N/A in the space.
4. You will be notified by mail regarding the status of
your application.
5. If you
have any questions about the application, please email us at
info@etrfoundation.com
Purpose: To provide scholarships as
funds permit to those seeking treatment for eating disorders in the St. Louis
area
Award Components: Awards will be presented as funds
permit and on a case-to-case basis with no scholarship value exceeding $1000
(one thousand dollars)
Criteria:
1. Applicant
must reside in the St. Louis area or be seeking treatment in the St. Louis area
(with the only exception being at Magnolia Creek)
2. Applicant
must demonstrate that they are taking positive strives towards recovery
Application Process:
Applicant
must submit the following items:
1. Completed
application form (if handwritten, please print legibly)
2. Personal
Essay. Please answer the question, “What does recovery look like to you?”
3. One (1)
letter from a medical professional detailing your current health and diagnosis
(be sure to have them include contact information)*
4. Optional,
but preferred: letters from your current therapist and a family member or
friend detailing the impact on your life*
5. Details
regarding the selection process are available on our website under “Scholarship
Information” but can also be obtained by requesting a copy.
6. The status
of your application can be found on http://www.etrfoundation.com/status.htm,
however, you must request an application code.
*Parts
denoted with an asterisks (*) may be
emailed to info@etrfoundation.com -
those received from health care professionals, however, MUST be emailed from
the providers’ work email and/or with an official letterhead or signature.
Additionally, if optional components will be received by email that must be annotated on a separate piece
of paper accompanying the application, otherwise the application will be
processed without those pieces.
Please
e-mail the application with accompanying articles as attachments, or mail the
application to:
Escape to Reality Foundation
ATTN: Kristie Ferreira
7109 South
Street
St. Louis,
MO 63143
Escape to Reality Foundation Scholarship
Application 2011 (revised August 5th, 2011)
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Please type or print your answers. If application is illegible it will
be returned to you.
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1.
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First Name:
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Last Name:
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2.
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Mailing Address::
Street: _________________________________________________________
City: State: ZIP:
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3.
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Daytime Telephone Number: ( ) Email Address:
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4.
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Date of Birth: Month Day Year
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6.
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Current Occupation:
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Duration
of Employment:
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7.
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Current treatment you are receiving/seeking (therapy, IOP,
IP, PHP, dietitian, etc) and where you are seeking it:
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8.
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List the name(s) and contact information of those involved
in your treatment:
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9.
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Current Treatment Expenses (out of pocket, please itemize and include frequency):
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10.
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Current Itemized Monthly Income (include any additional
sources of financial support besides salary):
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11.
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Current Monthly Expenses (Without treatment – please
itemize):
1. Rent –
2. Food –
3. Utilities –
4.
5.
6.
7.
8.
9.
10.
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12.
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If there is a significant amount not covered by your
monthly income, how do you pay for those expenses? (ie: you live with family
members)
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13.
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What support system do you currently have in place?
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14.
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What is your treatment history?
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15.
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What is your current perception regarding your health,
your eating disorder, and recovery? (anything you think would help us
understand how you feel regarding your condition)
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16a.
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What behaviors do you currently engage in and in what
frequency?
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16b.
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If applicable, how has 16a changed since you started
treatment?
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17.
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How has having an eating disorder impacted your life
financially?
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18.
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How has having an eating disorder impacted your life in
general (relationships, school, jobs, etc)?
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19. |
What are your personal interests and hobbies?
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20.
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Is there anything else not detailed here or in your
personal essay that should be considered?
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21.
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Personal
Essay
Please answer the following question below or attach
additional pages as needed:
What does recovery look like to you?
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I hereby affirm that all the above stated information
provided by me is true and correct to the best of my knowledge.
I hereby I am disclosing the contents of this application of
my own volition to the Escape to Reality Foundation and understand that if
chosen as a scholarship winner, according to ETR Foundation Scholarship policy,
I must provide evidence of continuing treatment in the St. Louis area (or I
must be a resident of the St. Louis area). I also understand that as a
contingency of the award, the amount
awarded will be given directly to the treatment provider.
Signature of scholarship applicant:
_______________________________________ Date: _________
Signature of Parent/Guardian (if under 18 years of age):
_________________________ Date: ______
