Our Financial Assistance Form

Thank you for considering a Victories program. To be considered for financial assistance complete the form below or you can download it. Questions? Contact Victories at 312-604-5013 or admin@victoriesformen.org.

Name
First Last
Phone
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What is your birth date?
MM slash DD slash YYYY
Who referred you to Victories?
First Name Last Name
Is this person your therapist?
- Yes
- No
What Victories Program Do You Wish to Attend?
What Dates Do You Wish to Attend?
Please Specify*
Please answer the following questions to help us more fully understand your financial need and interest in the Victories program(s) for which you are applying.
Please describe the amount that you can contribute to your program fee
(standard cost is $690, $895 for Couples)
What is the total amount you are able to pay towards the cost of the program?*
*
- I can pay this total amount now
- I would like to pay this amount in installments
Amount towards nonrefundable deposit ($50 minimum)*
Monthly payment amount (minimum $15)*
Payment Plan Duration in months (maximum 18 months)*
BreakThrough and Wisdom Years Weekend participants are strongly encouraged to join the Personal Growth Group (PGG) after the weekend. The standard fee for participation is $25 to cover facilitation costs.
I plan to participate in the PGG
- I can pay the full $25
How much are you able to pay?*
Why do you want to participate in this program and what do you hope to learn?*
Please describe your current financial situation and why you are requesting assistance.*
Victories is a non-profit organization with limited funds for scholarships. Our revenue from program fees does not cover our costs. This difference is made up through generous donations from our alumni community. Should your financial circumstances improve, would you be willing to consider helping other men by making a future contribution to the scholarship fund?
- Yes, I would consider making a future contribution when my financial circumstances improve
If any scholarship funds are awarded, I agree to write a brief summary of my experience (1-2 paragraphs) and allow Victories to use the written summary for marketing and alumni communication purposes. Summary submission can be anonymous. Submission should be emailed within 30 days of completion of the program for which scholarship funds were received.
- Yes, I am willing
Our mission is to give many more men the opportunity to experience the benefits of our programs. Would you be willing to help Victories accomplish this by committing to recruiting at least 1 man into a weekend or other program this calendar year
- Yes, I am willing
Please note: All of the information provided on this financial assistance application is confidential and only reviewed by the Victories Administrative staff. Weekend Leaders and Staff are not aware of which participants are on scholarship. We will be in contact to review the details of your application and to collect your payment information.

Financial Assistance Form

Our Financial Assistance Form

Please describe the amount that you can contribute to your program fee
(standard cost is $690, $895 for Couples)

BreakThrough and Wisdom Years Weekend participants are strongly encouraged to join the Personal Growth Group (PGG) after the weekend. The standard fee for participation is $25 to cover facilitation costs.

Want to help us reach more men and communities?

Contact Us

Menu

Financial Assistance Form

Our Financial Assistance Form

Please describe the amount that you can contribute to your program fee(standard cost is $690, $895 for Couples)

BreakThrough and Wisdom Years Weekend participants are strongly encouraged to join the Personal Growth Group (PGG) after the weekend. The standard fee for participation is $25 to cover facilitation costs.

Want to help us reach more men and communities?

Contact Us

Menu

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Please describe the amount that you can contribute to your program fee
(standard cost is $690, $895 for Couples)