Community Care Award Application
Metta Wellness Center
Please complete the following questions to apply for the Community Care Award.
More information can be found at www.metta-wellness.com/give
First and Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Best way to contact you? *
Provide your contact information: *
Email, phone, address, etc. Provide at least one.
Your answer
Do you have reliable transportation to Metta? *
Metta on the Avenue: 720 W 36th Street, Baltimore, MD 21211 | Metta at Yoga Village: 3000 Chestnut Avenue, Baltimore, MD 21211 ***Please note that treatment rooms at the Avenue require you to ascend two flights of stairs. Treatment rooms at Yoga Village require a few steps only. However, neither location is wheelchair accessible.***
Can you COMMIT to receive one massage every month for 6 months? *
How did you learn about the Metta Community Care Award? *
Your answer
Why do you want to receive massage and bodywork? *
Write as much as you like here. Please be specific, so we can give your application good consideration! Please describe any physical, spiritual, or emotional factors that effect your situation.
Your answer
Please describe why you need the award to be able to receive these services. *
Please describe any and all factors that contribute to your current situation and economic need. Factors may include access to income, health insurance, transportation, childcare, etc., or any other factors you feel are relevant.
Your answer
Are you able and willing to receive hands-on and/or energetic bodywork regularly for a period of one hour? *
Requirements: Must be comfortable receiving touch from different practitioners. Must be able to lie face up, face down, or on one side for long periods (20-60 minutes). Must be able to climb stairs to reach the treatment room.
*If you answered "No" or "Maybe" above, please elaborate.
Please describe any factors that might prevent you from being able to receive bodywork, or any factors that might limit the type of bodywork you are able to receive.
Your answer
Terms and Agreement *
By submitting this application, you agree to share this information with Metta Wellness and any of its practitioners. You understand that applications will be reviewed and an awardee will be decided at the discretion of Metta Wellness based solely on the information you provided. You agree that if you are chosen to receive the award, you will comply with the terms and requirements. You understand that any misrepresentation on your part, or any violation of the terms and requirements may cause you to forfeit the award in full or part. Metta Wellness will not be responsible to you for any loss to you, monetary or otherwise. If you agree to the terms, type your full name below.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service