Scholarship Sign Up

Date

Your Name (required)

Address

Email Address (required)

Phone Number

Date of birth

All information is confidential:

Are you a veteran?
 Yes No

Are you able to work at present?
 Yes No

If YES please state occupation, if NO what prevents you from working

How did you hear of the Stress Reduction Program?

What are your interests in the Stress Reduction Program at this time?

What do you aim to gain/ change form participation in this program?

Can you commit to 1 hour of home mediation / exercises daily while participating in the 8 week program?
 Yes No

By requesting financial support, you have indicated that you are unable to afford the full registration fee at this time. We ask that financial aid recipients pay a minimum of 50% of the program fee (current prices can be found on our website). Because of the demand on our limited funds, please consider paying more if you can. What is the total maximum amount, above the minimum 50%, that you could afford to pay to participate in this program?

Amount

What is your approximate total household income annually from all sources?

How many people depend on your total annual household income?

Do you have a diagnosed medical condition as the primary reason you wish to
participate in this program?
 Yes No

Please state medical condition:

Are there significant medical expenses associated with your medical condition?
 Yes No

Approximately how much is the amount of your annual medical expenses which you must pay “out of pocket”, i.e., expenses that are not reimbursed by any form of insurance coverage?

Do you have a significant financial burden on you?
 Yes No

Please describe:

What is the approximate total annual expense of this financial burden for you?

Please select one of the below:

$0.000 items