Scholarship Application

This is for individuals to complete to apply for the QAS service at a reduced rate. It is our way of giving back for those that want change. Once the completed application

First Name *

Last Name *

My email address is : *

A brief description how I got to this service or what drew me here? *

Why are you requesting a Scholarship? *

What services do you wish to apply for and who? (ie; Empower service? Location? Situation? and is it just for you or others in your family?) *

I have read and agree to the Scholarship Terms and Conditions on the website ( https://www.mycw.ca/scholarship-terms/ ) *

I agree to the Terms

I commit to providing feedback in the form of a monthly short survey in exchange for this service. *

I commit to complete monthly surveys.

I understand and agree that if I do not provide feedback as agreed to in the terms and conditions, my service will be cancelled and this service will not be offered as a scholarship for the rest of this life. *

Yes, I understand

Required

I commit that once I begin this service I will remain on the service for at least 3 months to see how it effects my life . *

I agree to 3 Months

I agree to my feedback being used in any form the Company chooses. We will never disclose personal information except as agreed to below. *

I agree the Company can utilize my feedback on a first name basis.

I agree the Company can utilize my feedback but ONLY anonymously.

I can commit the following amount per month in exchange for this service (please provide the amount below). $CDN *

I agree that I will review the amount I provide for this service every 6 months. *

I agree to re-evaluate the amount I can contribute every 6 months.

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This form was created inside of Clearly Conscious Energetics.