What is your first name and last name?*

What is your email address?*

Please confirm your email address:*

What is the best phone number for you?*

What is your date of birth?*

Which of the following most closely aligns with your racial identity? (select all that apply)*

How would you describe your gender identity?*

Are you currently working or in school? (select all that apply)*

IF OTHER work/school, please specify:

Have you served in the military?*

What is your highest level of education?*

What is your religion? (select all that apply)*

If OTHER Religion, please specify:

What is your current relationship status?*

Are you entering recovery from any of the following settings? (Select all that apply)*

Which of these categories best describes your total combined family income for the past 12 months?*

Are you covered by health insurance? (Check all that apply)*

If OTHER health insurance, please specify:

What are the primary substance(s) that brought you to your desire for recovery? (Please check all that apply)*

Other (Please specify)

Do you live in recovery housing now?*

When did you move into your recovery home? (Select one option)*

What is your confirmed move-in date for your recovery home?*

Have you ever lived in a recovery house (also known as sober living) or other recovery-based residence before?*

If yes, how many times?

What was your longest length of stay?*

Will (or are) any of your child(ren) staying with you in your recovery home?*

*Your response to this question is optional and will not be part of determining whether you are awarded a scholarship. We are interested in understanding the unique needs of people in recovery who have children so that we are able to think about ways to support people in this situation.

If at least one of your children will be coming with you to recovery housing, please list the age(s) of each child that will be coming with you.*

Please provide your recovery home staff contact information (or elected officer if at an Oxford House) below:

Name of your recovery home*

Name of a staff contact person (or elected officer if you're at an Oxford Home) at your recovery home*

Professional email address of staff contact person/elected OH officer listed above*

Phone number of your recovery home, including area code*

Mailing address of your recovery home*

City and State where your recovery home is located*

Zip Code where your recovery home is located*

What is your monthly rent amount at the recovery home you will be moving into?*

Use this part of the application to see how much money you spend in a month. Then, use this month’s information to help you plan next month’s budget.

Month*

Year*

My income this month

Income	Monthly Total
Paychecks (salary after taxes, benefits, and check cashing fees)*
Other income (after taxes) for example: child support*
Total monthly income*

My expenses this month

Expenses Monthly total

Income	Monthly Total
HOUSING
Rent or mortgage*
Renter's insurance or homeowner's insurance*
Utilities (like electricity and gas)*
Internet, cable, and phones *
Other housing expenses (like property taxes)*
FOOD
Groceries and household supplies*
Meals out*
Other food expenses*
TRANSPORTATION
Public transportation and taxis*
Gas for car*
Parking and tolls*
Car maintenance (like oil changes)*
Car insurance*
Car loan *
Other transportation expenses*
HEALTH
Medicine*
Health insurance*
Other health expenses (like doctors' appointments and eyeglasses)*
PERSONAL AND FAMILY
Child care*
Child support*
Money given or sent to family*
Clothing and shoes*
Laundry*
Donations*
Entertainment (like movies and amusement parks)*
Other personal or family expenses (like beauty care)*
Fees for cashier's checks and money transfers*
Prepaid cards and phone cards *
Bank or credit card fees*
Other fees*
OTHER
School costs (like supplies, tuition, student loans)*
Other payments (like credit cards and savings)*
Other expenses this month*
Total monthly expenses*

Are they any of the past 50 questions you would like to expound on?*

How did you hear about this 516 Light Foundation scholarship opportunity?*

Other (Please specify)

Are you currently in a treatment center?*

Please provide your current treatment center’s information (type n/a if not applicable)*

Are you working with a sponsor or mentor? If so, please provide name and number for reference.*

How much money are you requesting for this scholarship?*

How would a scholarship from 516 Light Foundation be helpful?*

Please add signature.*

Applicant completed signature.*

*Required Fields