1Valley Behavioral Health form a



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1Valley Behavioral Health FORM A

Carmen B. Pingree Autism Center of Learning

Application for Placement and Financial Assistance Application

2015-2016 Program Year


Please be sure to initial that all of the following are included Prior to submitting the application:
1. _____ That this form is completed in its entirety

2. _____ To attach a copy of your most recently filed federal tax return

3. _____ To attach copies of payroll check stubs for the previous three months

4. _____ To provide an explanation of special circumstances for your family that may

not be reflected in the above information

5. _____ That signatures are completed in all areas




Student Name:

Student’s Date of Birth:

Student’s grade for 2015-2016:

Current Grade and District:

1. Parent/Guardian Name:

2. Parent/Guardian Name:

Home Address:

Home Address:

City, Zip:

City, Zip:

Marital Status:

Marital Status:

Employer:

Employer:

Home Phone: Work Phone:

Home Phone: Work Phone:

How many dependents do you have?

How many dependents do you have?

Please answer the following questions. Circle when necessary.


* Has your child previously been approved by the Utah State Office of Education to

Receive Carson Smith Special Needs Scholarship Funds? YES NO


If NO, are you planning on applying for the Carson Smith Special Needs

Scholarship Funds YES NO


* Will you/your family be applying for this tuition reduction for more than one year? YES NO
*Is your child currently on Medicaid YES NO

If No, have your previously applied for Medicaid YES NO


*Do you have any other sources (family, clergy, church) that may be willing to YES NO

assist in the tuition payment.

If yes, how much do you feel they could contribute yr/monthly? ___________
* Have you ever filed for bankruptcy? If yes, please list the year(s) YES NO
*How much do you feel you are able to pay each month? $_________________

1Valley Behavioral Health FORM B

Carmen B. Pingree Autism Center of Learning

Application for Placement and Agreement to Pay with NO Financial Assistance (other than CSS) for 7th grade and above or Adjusted Gross Income over $115,000.00 and above.

2015-2016 Program Year
Please initial that all the following information is included prior to submitting application:

1. _____ That this form is completed in its entirety

2. _____ To attach a copy of your most recently filed federal tax return

3. _____ To attach copies of payroll check stubs for the previous three months

4. _____ That signatures are completed in all areas


Student Name:

Student’s Date of Birth:

Student’s grade for 2014-2015:

Current Grade and District:

Parent/Guardian Name:

Parent/Guardian Name:

Home Address:

Home Address:

City, Zip:

City, Zip:

Marital Status:

Marital Status:

Employer:

Employer:

Home Phone: Work Phone:

Home Phone: Work Phone:

How many dependents do you have?

How many dependents do you have?

* Has your child previously been approved by the Utah State Office of Education to

receive Carson Smith Special Needs Scholarship Funds? YES NO
If NO, are you planning on applying for the Carson Smith Special Needs

Scholarship Funds YES NO

Have you every filed for bankruptcy? ______yes ______no Year: 19_____ 20____
I/We agree to pay a full tuition for the 2015-2016 program year, if my/our child is accepted into the VBH Carmen B Pingree Autism Center of Learning. I/We additionally agree to provide the listed information above at the time of application. Furthermore, I/We authorize any required verification, including a credit bureau report. I/We understand that if this information is determined to be false or deceptive, such a determination will result in denial of services and I/we will be liable for payment of charges for services rendered. I/We understand that some services provided may qualify for health insurance reimbursement and will be billed to my/our insurance plan. I/We further understand that the reimbursement received will be deducted from my obligation.
Parent/Guardian Signature: _____________________________ Date: _______________
Parent/Guardian Signature:______________________________ Date: _______________

Complete and attach to Form A -OR- Form B




Specific MONTHLY Income Information




1 Parent/Guardian

2 Parent/Guardian

Wages (before deductions)







Pensions







Social Security Income







Alimony/Child Support







Dividends/Interest/Insurance







Rental Income







Estates and Trusts Income







Public Assistance/Welfare







Workers Compensation/

Disability









Food Stamps







Other







Total:







ASSETS

Cash/Checking

$

Investments

$

Savings

$

Stocks/Bonds

$

Other

$







Are there any extenuating circumstances that should be taken into account in determining potential financial assistance? You may attach an additional letter if you would like.




Application Agreement

I hereby state that the information given herein is true and complete. I authorize any required verification, including a credit bureau report. I understand that if this information is determined to be false or deceptive, such a determination will result in denial of uncompensated services and I will be liable of payment of charges for all services rendered.
________________________________________ ______________________

Signature of Parent/Guardian Date

________________________________________ ____________________

Signature of Parent/Guardian Date





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