Application | The Sherman Foundation

Please answer the following questions to the best of your ability, as we use this information to design a program that fits your individual needs. The questions are grouped into the following categories:

• Current Treatment Info / Recovery Plan
• Health Insurance Information
• Housing Information
• Transportation Information
• Employment Information
• Financial Information
• Legal Assistance Information

At the end of each category there is a "notes" section - feel free to include any additional comments in this area. We will contact you if we have any questions regarding the information you've provided once the application has been submitted.

Note – the information you disclose to The Sherman Foundation is confidential and will not be shared with any other party or person(s).

Name

First Middle Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Email

What is your clean date?*

What is the longest you have been clean?

Current / Most Recent Treatment Provider (Name of Facility & Counselor’s Name)

Treatment Provider’s Address

Street Address Address Line 2 City State ZIP Code

Treatment Provider’s Phone

Length of Treatment (if applicable)

Briefly describe your short-term recovery plan.

Briefly describe your long-term recovery plan.

Notes

SCHOLARSHIP PROGRAM

Grant Application

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