FINANCIAL AID APPLICATION

As part of its mission, the Fred J. Wellington Foundation supports families in need of financial assistance, helping them to receive research-based treatment for dyslexia at approved treatment centers. Please complete the following application and return to our offices. Applications are reviewed on a quarterly basis, and notifications will be given quarterly as well:  January 1, April 1, July 1 and October 1.


Contact Information
 

Name of Applicant:     _______________________________________   Date of Birth_______________


Parent(s) Name(s):    __________________________________________________________________


Home address:  ______________________________________________________________________



City, State and Zip:  __________________________________________________________________


Daytime Phone:____________________________   Mobile Phone:  __________________________


Email Address:  ______________________________________________________________________



Financial Information


Combined 2013 Family Annual Income:                                              $_______________________


Combined Total Liquefiable Funds (includes Savings and Trusts):      $_______________________


Number of Dependents Living at Home:                                               _______________________


Has the applicant been tested for language deficiencies? (circle)              Yes              No


If yes, please list conditions and including dates and treatments: ___________________________

_____________________________________________________________________________________


Select preferred treatment center: (circle one)                                 Wellington-Alexander Center

                                                                                                          The Morris Center

I acknowledge that all the information provided above is true.

 

________________________________________                _____________________________

Signature of Applicant (or Guardian)                                   Date

 

 

Please send to:  Fred J. Wellington Foundation, 9821 E. Bell Road, Suite 100, Scottsdale, AZ  85260