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SCHOOL/PROGRAM

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APPLICATION

REQUEST TO BECOME A PARTICIPATING SCHOOL/PROGRAM

Program Name:

Request Completed By:

Date Completed:
Example: 03/06/2007     /     /

Please Initial Criteria Below

Oversight agency membership in good standing (list all appropriate)
         Agency

Program type meets criteria (please select)
         Emotional Growth Program
         Therapeutic Boarding School
         Special Needs School

Our Length of Stay (LOS) meets the one year criteria
        LOS is months

Psycotherapy is a component to our program

We have an academic accreditation from:

Our Parent Empowerment Survey results are

We have no religious affiliation

We have a parent participation/education program

Participating students' tuition is discounted 30%

As the authorized representative of this program, I accept the payment terms as set by The Foundation to be quarterly, in arrears, by credit card

As the authorized representative of this program, I agree to the involvement of The Program in The Foundation’s fund raising efforts

I, (Print Name and Title), am the authorized representative of

(The Program) do hereby certify that the above is a true and accurate representation of our program.

Electronic signature (your name here serves as your signature)

Date:   /    /

School/Program Name:
Authorized Representative:
Address:
Phone:   -    -
Fax:       -    -
Email:

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