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Scholarship Application
Application Process Information:

Application Due Dates: Applications will be accepted and funds distributed quarterly. The deadline is the last day of each calendar-year quarter (March 31st, June 30th, September 30th, Dec 31st. If the deadline is on a weekend or holiday, applications will be due the following business day.

Application Submission:
-Applications must be completed on our form and received by 11:59 p.m. on the due date.
-See the application form for delivery options.
-Applications do not roll-over to the next scholarship cycle and must be resubmitted each time a scholarship is desired.

After Applying: Applicants will be notified within two weeks of the application deadline whether their scholarship request is being fulfilled. At that time, accepted applicants will be required to submit further verification and final documentation. This documentation must be received within one month of the request.

Completing the Application Form:
• Every question must be answered, according to the directions, for the application to be complete.
• Incomplete applications are not considered for funding.
• Assistance in completing the application may be provided upon request.

Name *
Your answer
Address *
Your answer
Email address *
Your answer
Primary Diagnosis *
Your answer
Date of occurrence/injury *
MM
/
DD
/
YYYY
Secondary Diagnoses *
Your answer
Describe your current exercise program *
Your answer
How would you describe your current level of fitness? *
Your answer
Indicate any therapy you have received over the past year *
Your answer
Describe your current level of physical activity during the day *
Your answer
Indicate what SPECIFIC goals you hope to accomplish in participating at the Fitness Center *
Your answer
How many days a week do you plan on attending the fitness center? *
Your answer
Do you have available transportation to get to the fitness center? *
Your answer
If your request is for transportation, describe what is required for your transportation *
Your answer
Participants are expected to make some contribution to the cost of fitness center membership (minimum of $50 per month.) Indicate here what contribution toward the monthly fee you will be able to afford *
Your answer
When possible, we ask that scholarship recipients contribute to the organization in a volunteer capacity. Please indicate ways you could volunteer to give back to the program: examples include data entry or computer support, cleaning, greeter, driver for other participants, answering phones, assisting in fundraising, etc. *
Your answer
What is your annual household income? *
Your answer
Indicate how many children and how many adults are dependent on this income? *
Your answer
List the scholarship amount you would like to receive *
Your answer
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