PCO Hope Scholarship Application

PCO Hope Memorial Scholarship Application

The PCO Hope Memorial Scholarship program assists individuals who are transitioning from inpatient treatment to sober living. Scholarship funds provide short term rental assistance to allow individuals time to settle into their sober living home and find employment.
All applicants must have a primary residence within Plymouth County.

Please be sure to include the case manager referral form with your application. Both individual and case manager applications are needed in order to review scholarship requests. All forms can be found on our website at: https://www.pcohope.org/paving-the-path

Please fill out this form completely so we have a full understanding of your needs.

A member from our Board of Directors will be in touch with you should there be any additional questions or information needed.

Scholarships can be awarded up to a maximum of $500.

Transitional benefits can be awarded up to a maximum of $250.
I am applying for:*

Scholarship (all first time applicants)Transitional Benefits (if you've previously received funding from us)
TRANSITIONAL BENEFITS APPLICANTS

60, 120 and 180 days after receiving a PCO Hope Scholarship, individuals residing in a structured sober living environment are eligible for additional benefits through our Transitional Benefits program. These funds require their own application and referral form each time funds are requested.
Date of Request:*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Date of Birth:*

MonthDayYear
Date
Hometown (town that is or would be listed on your drivers license - the location of your sober home is not considered your hometown)*

Town name required - please do not enter "Homeless"

Town
Address of most recent residence (this should not be the address of your sober home)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone #:*
Please enter a valid phone number.
This phone number belongs to:*

MyselfCase ManagerHouse ManagerFamily/FriendOther
What is the best way for us to contact you?*

PhoneEmail
Approved Sober Homes

Below please find a list of sober homes that we are able to provide scholarships to. If you are applying for a scholarship to a home that is not on the list, please complete the application and we will reach out to the house manager/owner directly to complete an internal review with them before submitting your application for review/approval.
- Crimson House, Rockland
- East Coast Recovery, Hanover, Weymouth & Quincy
- Evergreen House, Wareham
- Grace’s House, Bridgewater
- Hope Beyond Hope, Weymouth
- Journey House, Bridgewater, Middleboro & Taunton
- Limitless Recovery, Abington
- Nikki’s Place, Braintree
- Norfolk County Sober Living, Quincy
- Rockland Recovery, Rockland
- Rosemary’s House, Plymouth
- A Vision for Hope, Weymouth
Name of treatment facility you are coming from (required for first time applicants - enter "N/A" if this is not your first application with us):*
Name of case manager at treatment facility (required for first time applicants - enter "N/A" if this is not your first application with us)*
Phone number for your treatment facility case manager (required for first time applicants - enter "N/A" if this is not your first application with us")*
Date arrived / expected date of arrival at sober home:*

MonthDayYear
Date
Name of sober home you will be/are living at:*
Enter treatment facility name for scholarship requests, sober living home name for transitional benefits requests
Sober Home House Manager:*

First NameLast Name
Sober Home House Manager Phone #:*
Please enter a valid phone number.
Sober Home House Manager Email:*
example@example.com
Do you give permission for us to contact your case manager or house manager should we have questions for them pertaining to your application/scholarship?*

YesNo
Location of your current treatment provider or sober living home:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Weekly Cost / Requested Amount:*
Maximum of $500. Enter weekly rent amount for scholarship requests. Enter amount requested for transitional benefits.
Essay:*

minimum 200 words0/0
Have you received funds from us previously?*

YesNo
# of times you have received funds from PCO Hope:*
Enter 0 if this is your first time submitting an application
Do you have any pending legal issues?*

YesNo
Are you currently taking any medications?*

YesNo
Do you currently have a source of income?*

YesNo
How did you hear about our scholarship program?*

Family/FriendCase Manager/House ManagerTreatment ProgramReceived Previous ScholarshipOther
What is your age range?*

18 - 2930 - 3940 - 4950 - 5960 - 69Over 70
Gender:*

MaleFemaleNon-binaryPrefer not to answer
How many times have you been in treatment before?*

01-34-6+
Marital Status:

MarriedSingleDivorcedWidowedSeparatedOther
Ethnicity:

Asian or Pacific IslanderBlack or African AmericanHispanic or LatinoNative American or Alaskan NativeWhite or CaucasianMultiracial or BiracialRace/Ethnicity not listed
Do you have any children?:

YesNo
How many children do you have?:
Referral form:*

I have requested that my case manager complete the referral form located at: https://www.pcohope.org/paving-the-path and understand that my application will not be reviewed until that is received.
Is there anything else you'd like to tell us about yourself?
Completing this application does not guarantee a scholarship. Please give up to 7 business days for a response. Applications will only be considered for residents of Plymouth County. Maximum scholarship award is $500. Award letters will be emailed to the address that you have provided on this application.
Your signature:*

Clear
For PCO Hope Use Only

Applicant: please do not enter any information in this area
Application Approved:

YesNo
Approval Date:

MonthDayYear
Date
Should be Empty:

PCO Hope Memorial Scholarship Application

Approved Sober Homes

For PCO Hope Use Only