2021 LeadingAge Ohio Foundation Adult Day Scholarship Application

For mission-driven, values-based adult day providers who are willing and able to sign the LeadingAge Ohio Values Statement, a 50% scholarship in 2020-2021 dues will be offered if two of the three conditions below are met:
• A maximum daily client capacity of 25 or less;
• Operating history of less than 5 years;
• Insufficient reserves to fund 30-days of operations (i.e. 30 days cash on hand).
If an organization has more than 90 days cash on hand, a scholarship will not be provided. Please note that LeadingAge Ohio has a policy that requires all facilities within a multi-site to join.
2021 Dues: $560. With 50% scholarship, 2021 Dues: $280.
Scholarship funds have been provided by the LeadingAge Ohio Foundation for the 2021 calendar year. The funds will be distributed until the existing scholarship fund is exhausted and scholarships will be granted on a first-come, first-served basis.
Adult Day Scholarship
If you need assistance completing this form please contact:
Kathryn Brod
kbrod@leadingageohio.org
614.545.9014

STEP 1: Applicant Information:

Organization
Work Address
City
State
Zip
Work Phone
Website
Primary Contact's Name
Primary Contact's Title
Primary Contact's Email

Type of Ownership

Please check applicable category.
Governmental
Not for Profit
Proprietary
Is your program licensed?
No - unlicensed, under 5 people served
Yes

If you have a parent corporation/owner other than that listed above, please provide the following:

Parent Organization
Parent Organization Address
Parent City
Parent State
Parent Zip
Parent Organization Phone
Parent Organization Contact
Parent Contact Title
Parent Contact Email

STEP 2: Financial Information:

Total Annual Revenue for most recent complete year:
Start Date of Operations:
Cash Reserves:

STEP 3: Program Information:

Have you seen an increase in the need of adult day services offered with your organization?
Number of FTEs:
Total number of Full Time Staff:
Total number of Part Time Staff:
Total number of clients served daily:

STEP 3: Statement of Commitment:

By checking here, I acknowledge that the ADS Administrator/owner of the organization is aware of this application and all information supported as part of the application. A signed LeadingAge Ohio Values commitment statement has been completed.
   - denotes required fields

Our national partner, LeadingAge, is an association of 6,000 not-for-profit organizations dedicated to expanding the world of possibilities for aging. Together, we advance policies, promote practices and conduct research that support, enable and empower people to live fully as they age.