Financial Assistance Application

We all need help from time-to-time. We understand that and are here to help to the best of our ability. To this end, we offer our Financial Assistance Program.

The Injury Prevention Project’s Financial Assistance Program is designed to serve those in financial need with fairness, consistency and compassion.

If you would like to participate in one of our subscription programs but have difficulty paying for the program, we want to work with you to provide as much assistance as we can. This service is free and confidential.

We do require your participation in the process, including a completed application form with current financial information. The information that you provide will be reviewed and used to evaluate your ability to pay your program.

Those who qualify for financial assistance will receive a specific discount on the service, up to a 100 percent discount for charity programs.

If you do not qualify for financial assistance or charity care from Injury Prevention Project and still need assistance, we do offer a monthly payment plan.

I certify that all information in this application is true and correct to the best of my knowledge, and I give Injury Prevention Project permission to investigate the information provided. I understand that the information will be used to evaluate my ability to pay for services provided by Injury Prevention Project.

Name

Email Address

Family Size

Gross Annual Income Gross Annual Income 0-24,999 25,000-39,999 40,000-54,999 55,000-69,999 70,000-84,999 85,000-99,999 10,000-149,999 150,000+

Explanation of Need

What else would help?

Signature

Date

Financial Assistance Application

Subscription Programs

Running Programs

Free Programs