Speech and Feeding Therapy

First Name *

Last Name *

Email

Phone 1

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Data Privacy & Consent

Yes, I would like to receive text messages from Team Iron Will.

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Login Name

Password

Retype Password

Child's Full Name

Relationship to child

Why are you requesting a scholarship? *

Please be as specific as possible with your situation.

Type of therapy being requested

If "other" therapy please describe and include a link to the therapy you are requesting help with.

How much are you able to contribute toward the cost of the class? *

Team Iron Will offers both full and partial scholarships.

Your Child's Diagnosis

Down syndrome

Trisomy 21

Mosaic Down syndrome

Other

Proof of Diagnosis

Household Income

Income Documentation

Number of People in Household

Have you received previous assistance from Team Iron Will? *

Yes

No

If yes, can you please share how you've been helped by Team Iron Will?

If unable to attend

If we are unable to attend the therapy, I agree to give Team Iron Will 3 days advance notice so that another family may benefit from the scholarship.