Financial Aid

Financial Aid Application

Steiner Health Life Force Intensive Session
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Have you received any need based financial aid from Steiner Health in the last 12 months?

Yes No
Month and year of the session you are applying for:

Number of members in the household:
Total adjusted gross income:
Supplemental monetary support:
Please explain:
How much are you able to pay now for this session?
How much are you able to pay in the next 6 months?
How much assistance can you expect from family and relatives?
We encourage you to ask your community for assistance (or have someone ask on your behalf).
How much can your friends, church, or community contribute?
Please Upload All Household Tax Returns From Last Year:

If you have no taxable income, please include a paycheck stub, social security benefits letter(s), or ADC forms. If the payer is in the U.S. on a student or non-working visa, they must provide appropriate documentation of this status. Please provide documentation summarizing the amount of support granted to the payer by any other party , such as church, family, friends etc.
Cancel of

An applicant's financial documentation does not always reflect their current fiscal situation. Therefore, please explain any special circumstances surrounding your need for financial aid, providing as much detailed information as possible. Exceptional situations might include sudden or prolonged illness, loss of job, business loss, etc.
Special Circumstances:
In what ways are you able to help the mission of Steiner Health?

Distributing Brochures Referring Other Patients Writing a Testimonial Statement Other
Other:
I declare that, to the best of my knowledge, the information on this application is true, accurate, and complete.

Clear
Today's Date:

Month Day Year
Date
Additional information may be requested if necessary.

If you have questions about the financial aid program, please call 734-222-1491
Should be Empty:

Financial Aid Application