First Name *

Last Name *

Phone *

Email *

Date of birth *

Address

Street Address

City

State

Country

Postal code

How Willing Are You To Change Your Diet? *

How Willing Are You To Change Your Activity Level? *

What Other Chronic Disease do you have?

Scholarship Agreement *

I understand that this is an application for a scholarship and filling out this form does not mean you have been selected.

If I am a selected recipient, I understand that the scholarship can be revoked if I do not abide by the rules of the program or the gym.

I am committed to attending at the class time advertised and I meet the prerequisites of the scholarship application.

I have been cleared to exercise by my primary care doctor.

Upon the end of a scholarship, if awarded, if I cannot afford the current monthly membership fee, I am willing to provide a bank statement so the owners can verify and justify a rate adjustment that fits into my current living situation.

I agree to be interviewed for a documentary series on this program that will be shared publically on our YouTube Channel and other Social Media.

How did you hear about this application? *

What would receiving this Scholarship mean to you and why are you interested? *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (XXX) XXX-XXXX for assistance. You can reply STOP to unsubscribe at any time.

Signature *

Clear

Privacy Policy | Terms of Service