Complete the SJS Application

1. Your Name: (Required)

2. Your Email: (Required)

3. Your Date of Birth: (Required)

4. Marital Status: (Required)

SingleMarriedDivorcedWidowed

5. Address: (Required)

Street Address:
City/State:
Zip Code:

Are you: (Required)

RentingOwn/Purchasing your homeLiving in a family members/friends homeOther

6. Number of Dependents financially responsible for: (Required)

7. Phone: (Required)

Home
Mobile
Work

8. Have you ever applied for the Shannon J. Scholarship in the past? (Required)

YesNo

9. Do you personally know anyone currently associated with Shannon J. Scholarship, Inc. (ie:
Board Members, friends or family members of its Staff) (Required)

YesNo
(Yes) Who:

10. How did you hear about Shannon J. Scholarship, Inc.? (Required)

11. Please list an alternative contact for SJS to reach in case of an emergency or if SJS is unable to make contact with you. (Required)

Name
Relationship
Phone Number

12. What Clean and Sober Living Program/Treatment Center/Counseling Service are you seeking assistance for? (Required)

13. Are you currently Employed? (Required)

YesNo
Where:

14. Please list all sources of income (If NONE enter NONE): (Required)

15. What is your Estimated Combined Yearly Household Income: (Required)

less than $10,000$20,000-$30,000$40,000-$50,000$10,000-$20,000$30,000-$40,000more than $50,000

16. Do you have a checking and/or a savings account? (Required)

YesNo

17. Are you willing to provide a current copy of bank statement? (Required)

YesNo
Shannon J. Scholarship, Inc. will only use this information to insure that the Scholarship is not being defrauded or abused. The information will also help Shannon J. Scholarship, Inc. to better understand your financial situation.

18. Do you currently have medical insurance? (Required)

YesNo
Have you contacted your provider for benefits and eligibility? (required)

YesNo
What portion of rehabilitation will they cover?

19. Have you sought financial help from:

Family
Whom
Clergy
Whom
Other
Whom
Prior to applying for SJS please seek assistance from the above. Every little bit will help insure that SJS will be available to more people seeking help. (Example: family able to cover every other week , SJS covers other) please contact SJS if you needed further explanation.

20. Are you seeking: (Required)

Full ScholarshipPartial Scholarship
If seeking s Partial Scholarship, please specify weekly amount needed $

21. Are you a United States Military Veteran? (Required)

YesNo
If yes, are you in contact with the VA?
YesNo
There are many recourses available through the VA to assist Military Veterans. SJS is willing to help you get in contact with a VA representative.

22. Shannon J. Scholarship, Inc. does recognize that many struggle with unique challenges. Unfortunately, no application can perfectly represent unusual, unexpected, or extenuating circumstances. For this reason we invite you to share with us the financial difficulties you face:

23. Please describe your Drug and Alcohol History and any Treatment History:

Sobriety Date: (Required)

Number of Days Clean:

Applicant Electronic Signature: (Required)

Date:

Applicant Message: (Optional)