Linda L. Nickles Memorial Scholarship

This application form is designed to provide the selection committee with information about your child and your family as well as your child’s therapeutic need. Selection is primarily based on therapeutic and financial needs.

Applicants must submit documentation of eligibility for services and:

Be under the age of 19
Be evaluated for therapeutic need
Agree that more than three unexcused absences will result in the termination of the scholarship.

Parent(s) Name:

Child's Full Name

Full Address

Phone Number

Email

How many are in the household?

Net Income of household

Do you have other income sources?

Yes

No

If you answered yes to the question above; how much do you receive from those additional sources?

Do you have reliable transportation for your child's therapeutic appointments?

Yes

No

Do you have insurance?

Yes

No

Name of Insurance Company (Type N/A if not applicable)

Does your insurance cover therapeutic services for your child? If so, what amount do they cover?

How much do you feel you can afford per visit? (Visits are typically $65/hr)

Have you applied for funding through TEFRA (Tax Equity and Fiscal Responsibility Act of 1982)?

Yes

No

Is your child receiving therapeutic services through his/her/their school?

Yes

No

Is your child receiving services through SoonerStart?

Yes

No

Have you applied for in-home waiver support through DDS?

Yes

No

Have you completed an application for services with the Opportunity Center, Inc.? (We must have an application on file to coincide with this scholarship form)

Yes

No

Please upload a document from your child's therapist with their contact information and a detailed plan outlining what services your child needs, and the expected duration of those services.

Once the application is reviewed and the scholarship is granted, the therapist must show proof of services provided in order to receive funds. The scholarship will be made payable to the therapist for direct payment of services.