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
Your answer
Email address
Your answer
Age
Your answer
Date of Birth
MM
/
DD
/
YYYY
Location and Time Zone
Your answer
Phone Number
Your answer
Home address
Your answer
Please describe your current status
Middle School/Junior High student
High School student
College/University student
Trade school student
Working
Other:
Clear selection
Do you have access to the internet, Zoom calls, email?
Your answer
How did you hear about Food Liberation and or the Teen Mentorship?
Your answer
Why are you specifically interested in Food Liberation?
Your answer
What best describes your CURRENT health status?
Diagnosed Anorexia Nervosa
Diagnosed Bulimia Nervosa
Diagnosed Binge Eating Disorder
Diagnosed Eating Disorder Not Otherwise Specified
Disordered Eating
Binge Eating
Restrictive behaviors
Other:
Health history: please check all that apply
Diagnosed Anorexia Nervosa
Diagnosed Bulimia Nervosa
Diagnosed Binge Eating Disorder
Diagnosed Eating Disorder Not Otherwise Specified
Disordered Eating
Binge Eating
Restrictive behaviors
Extreme dieting
Other:
Have you received any treatment/care for your eating disorder/disordered eating? Please describe in detail
Your answer
Are you currently seeing a therapist, psychologist/psychiatrist, doctor, dietitian, or other providers for your eating disorder/disordered eating? Please specify.
Your answer
Please describe your historical and current relationship with food in detail (weight and numerical values may be omitted)
Your answer
Please describe your historical and current relationship with your body in detail (weight and numerical values may be omitted)
Your answer
How does your current relationship with food and your body affect other areas of your life? (relationships, school, work, hobbies, etc)
Your answer
What is your understanding of food freedom/ intuitive eating?
Your answer
What is your desired outcome of the mentorship? (How do you want to feel? What would change in your life?)
Your answer
Are you ready to let go of dieting and restrictive behaviors?
Your answer
Are you comfortable sharing your journey with mentors and other participants?
Yes
No
I'm not sure
Clear selection
If you are under 18, have you discussed the mentorship program with your parent/guardian?
Yes
No
I am 18 years old or above
Clear selection
Is at least one parent/guardian available to be involved? (Check in sessions with mentor)
Yes
No
I'm not sure
Clear selection
Parent/Guardian phone number
Your answer
Parent/Guardian email address
Your answer
If you are selected for the mentorship, will you be available to complete all assignments and show up for all schedule calls?
Yes
No
I'm not sure
Clear selection
Will you be able to provide a written or video testimonial upon completion?
Yes
No
I'm not sure
Clear selection
If you have any questions, concerns, or additional remarks, please enter here.
Your answer
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