Empower Hour Financial Aid

Your (Parent/Guardian) Name *

First

Last

Your Email *

Your Mobile Phone Number *

Your Address *

Address Line 1

Address Line 2

City

State

Zip Code

Child Name *

First

Last

Child Date of Birth *

When was your child diagnosed with scoliosis? *

What type of treatment is your child doing for his/her scoliosis? *

How has scoliosis impacted your child's life and your family's life? *

How do you think your child will benefit from The Empower Hour? *

When would your child like to begin The Empower Hour? *

Average Household Income *

Size of Household (# of People) *

Please upload a hardship letter explaining your circumstances. *

Drag & Drop Files, Choose Files to Upload

Empower Hour - Financial Aid Form