Break Free Scholarship Application

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The Break Free Foundation Scholarship awards scholarships to individuals who meet the following criteria:

– You are in need of treatment for a substance use disorder or a co-occurring disorder,

– You are serious about entering into recovery,

– You are ready to commit to a minimum of 30 days in an inpatient treatment program,

– You have insufficient financial resources to cover the costs of treatment,

– You have exhausted other avenues of support for seeking out treatment,

If you meet the criteria above, please consider submitting our scholarship program.

Based on the availability of scholarships awarded by the Recovery Centers of America and the Realization Center, the Break Free Foundation is pleased to be able to offer scholarships to attend a rehabilitation and outpatient program to individuals who otherwise would not be able to afford these recovery resources.

In order to apply for a Break Free Foundation Scholarship, the applicant must complete the following application to Break Free by the last Monday of the Month.

Email *

What is your First and Last Name? *

Do you have a prefered name that you go by?

What is your address? *

State *

City *

Zip Code *

Phone Number *

Is it ok if Break Free calls your phone and leaves a message for you? *

Yes

Is it ok if Break Free sends text messages to your phone? *

Yes

What is your date of birth? *

What is your age? *

What is your Sex (Assigned at Birth)? *

Male

Female

What is your gender identity?

What is your Social Security Number?

Name of the person completing this form? *

Relationship to applicant? *

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