Breathworks Program Application For Individuals with CF

The Inspire Breathworks program is a complimentary, sustainable, holistic, and educational health solution to balance the body, mind, and emotions while improving overall well being of individuals with CF by increasing lung function.


INSTRUCTIONS TO APPLY:
*Applicants are required to provide all of the following documents in order to be considered

1.   Application
       -  Fill out in full.
   


2.   CF Verification Letter from social worker or doctor
        -  Emailed directly to BWP@pipersangels.org from their work email.


3.     Video Submission
       -  In good lighting and a quiet area, take a brief selfie-style video (landscape format)
       -  Say your name, that you have cystic fibrosis, and what improved breathing means to you

       -  If you do not have CF, but are applying for someone who does, please include them in the video and say your relation to that person and they have CF, and how the program will help your family
       -  Please put applicants name in subject line 
       -  Emailed BWP@pipersangels.org with applicants name in subject line

**For individuals with privacy concerns please email us if you are not comfortable submitting your video. We respect your needs and boundaries and this will not hinder you from receiving the grant/program participation.

4.  Photo Submission: One (1) Photo of what the reality of CF looks like for you. These photos/videos serve the purpose of inspiring more people to donate to the Piper’s Angels Foundation programs to help more CF families in need

 -  MUST be JPG or PNG files.  NO PDFs

 -  Must be original raw photos.  Cannot have filters, be edited, or be a screenshot.

 -  1 photo of what the reality of cystic fibrosis looks like for you

 -  Email to BWP@pipersangels.org  with applicants name in subject line

**For individuals with privacy concerns please email us if you are not comfortable submitting your photo. We respect your needs and boundaries and this will not hinder you from receiving the grant/program participation.  


5.   Photo/Video Release Form
        - Must download and SIGN  "PAF Photo Release Waiver" from website.
        - Email the form to  BWP@pipersangels.org.  
        - Don't forget to include applicant's name in the subject line.


6.  Release of Liability Waiver

       - Must download, fill out,  and sign  "Release of Liability Waiver" 
       - Email back to BWP@pipersangels.org.


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Email *
First Name  *
Last Name  *
Date of Birth *
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Phone Number *
Street Address *
City *
State or Country if outside US *
Required
Zip Code *
Country *
CF Care Center Name *
CF Care Center City *
Who were you referred by? *
If 'Other' Referral please enter here:
What is your breathwork practice experience? *
What was your most recent FEV1 measurement? *
What was the date of your most recent FEV1? *
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DD
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Other than CF,  what physical pre-existing medical conditions do you have?
Please list any other physical pre-existing medical conditions you have:
What pre-existing mental conditions do you have?
Please list any other pre-existing mental conditions you have: 
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