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The Merrimack Valley Prevention and Substance Abuse Project is committed to engaging public and private community members to work together promoting awareness, education, prevention and treatment of substance use in our communities. Together we will make a difference.

Amount Requesting *

Manager's Name

Sober Home Name

Sober Home Address

Country

City

State

Zip code

Recipient's Name

Phone

Email

Name

D.O.B

Age

Address

Country

City

State

Zip code

Phone *

Email *

Sobriety Date *

Do you currently have a sponsor *

Yes

No

Are you currently attend meetings *

Yes

No

Are you currently in school *

Yes

No

Are you currently employed *

Yes

No

Have you applied for previous scholarships with MVPASAP? *

Yes

No

If so, when?

Reason For Request *

Recipient agrees to the following:

Monthly updates for 1 years. RE: recovery, work, school. Report relapses. Volunteer at 2 MVPASAP Events.

Agree to terms *

agree

By checking this box you agree that all information entered in this form is accurate and you agree to the terms listed.and if accepted for a scholarship you agree to volunteer at two MVPASAP events with the year.

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