David Lynch Foundation | Scholarship Application Form

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FULL SCHOLARSHIPS FOR INDIVIDUALS THAT HAVE EXPERIENCED DOMESTIC OR GENDER-BASED VIOLENCE OR SEXUAL ASSAULT ARE CURRENTLY ONLY AVAILABLE IN NYC.

Referred by *

First Name *

Last Name *

City, State & Zip Code *

Phone Number *

Email Address *

How would you prefer to be contacted? *

Phone Call

Other:

Reasons for wanting to learn TM (Are you a survivor of DV or Sexual Assault?) *

Are you willing to complete four, short (3-5 min) surveys: one prior to learning TM as well as post-instruction surveys at 1, 3 and 6 months? These voluntary and confidential surveys are crucial to the continuing funding of our survivors of Domestic Violence (DV) and Sexual Assault program. You will still be able to receive a full scholarship, however, if you decide not to participate in the surveys. *

I am happy to complete all four surveys.

I prefer to decline, thank you.

Required

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