Food Liberation Teen Mentorship Scholarship Application (winter 2021)

Application due February 5, 2021.

Qualifications: Applicant must be a teen. Applicant must submit this application form and parental/guardian consent form if under 18 years of age.

Selection will include interview with applicant and at least one parent/guardian. Selected recipient will receive 100% scholarship for Food Liberation Teen Mentorship starting February 2021 under the guidance of a Registered Dietitian.

Expectations: If you are selected and enroll in the mentorship, you will be expected to complete all assignments and attend all scheduled calls. You will also be asked to provide a testimonial upon completion. Parent/guardian are expected to be involved in the program.
Full Name
Email address
Age
Date of Birth
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Location and Time Zone
Phone Number
Home address
Please describe your current status
Clear selection
Do you have access to the internet, Zoom calls, email?
How did you hear about Food Liberation and or the Teen Mentorship?
Why are you specifically interested in Food Liberation?
What best describes your CURRENT health status?
Health history: please check all that apply
Have you received any treatment/care for your eating disorder/disordered eating? Please describe in detail
Are you currently seeing a therapist, psychologist/psychiatrist, doctor, dietitian, or other providers for your eating disorder/disordered eating? Please specify.
Please describe your historical and current relationship with food in detail (weight and numerical values may be omitted)
Please describe your historical and current relationship with your body in detail (weight and numerical values may be omitted)
How does your current relationship with food and your body affect other areas of your life? (relationships, school, work, hobbies, etc)
What is your understanding of food freedom/ intuitive eating?
What is your desired outcome of the mentorship? (How do you want to feel? What would change in your life?)
Are you ready to let go of dieting and restrictive behaviors?
Are you comfortable sharing your journey with mentors and other participants?
Clear selection
If you are under 18, have you discussed the mentorship program with your parent/guardian?
Clear selection
Is at least one parent/guardian available to be involved? (Check in sessions with mentor)
Clear selection
Parent/Guardian phone number
Parent/Guardian email address
If you are selected for the mentorship, will you be available to complete all assignments and show up for all schedule calls?
Clear selection
Will you be able to provide a written or video testimonial upon completion?
Clear selection
If you have any questions, concerns, or additional remarks, please enter here.
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