Child Impact Program Tuition Assistance – The Mental Health Center

Child Impact Program

Discount Eligibility Request

Please complete the form in it’s entirety and then submit.

Once the financials are reviewed, you will receive a phone call to discuss the outcome and next steps.

Submission of this form DOES NOT automatically register you for a Child Impact Class.

Your information will be reviewed against income guidelines to determine if you qualify for assistance. After a review is conducted, you will receive an email from training@mhcgm.org advising you of the findings, with instructions as to how to register for the course with any application tuition assistance.

Please check ONE:*
- I am living without other adults due to divorce/separation. Report only for yourself
- I am part of a household that shares income. Report for the total household
Attendee Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Please check one option below and email documentation to training@mhcgm.org. You will not be able to register for a Child Impact seminar until we have received proof of documentation and have determined your eligibility for tuition assistance. Please note that the information provided may be requested by the New Hampshire Judicial Branch for verification.*
- I am currently receiving need-based assistance and would like the fee waived or reduced. I will email you verification of public assistance (a copy of TANF, EBT, Medicaid, Disability, or Food Stamps card - OR most recent official letter stating my benefits) Email to: training@mhcgm.org
- I am not receiving need-based assistance but I am unable to pay the full fee and request that the fee be reduced or waived. I have completed the State of NH Judicial Branch Financial Affidavit form. I will email you a copy of the NH Judicial Branch Financial Affidavit form to: training@mhcgm.org
Comments
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