Application for Partial Scholarship to Enroll in the Innergize Your Life Program

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Hello! I'm glad that you are interest to join the Innergize Your Life Group Program, where we do the inner work to address the root issues contributing to your eating struggles, take your power back from food and learn to care for yourself from a place of love. I understand finances can be a barrier to say YES to yourself and this opportunity to improve your relationship with food, eating and your body for good... but I don't want it to be. Guided by my belief that everyone among a diversity of communities deserves an equal opportunity to heal, I offer a few partial scholarships to those who demonstrate both financial need and a commitment to this work.

Name (First & Last) *

Email *

Ethnicity *

Caucasian

African-American

Latino or Hispanic

Asian

Native American

Native Hawaiian or Pacific Islander

Other:

Required

Estimated annual household income *

$100,000

$ 80,000- 100,000

$ 60,000- 80,000

$40,000- 60,000

$20,000- 40,000

Less than $20,000

Are you able to provide evidence of annual household income if requested? *

Yes

Other:

Please explain why you desire to participate in this group program at this time? *

Please explain why you desire to receive a partial scholarship to participate?

The partial scholarship brings your monthly investment down to $250/month (for 6 months). Are you able to agree to this investment? *

Yes

Other:

If no, what is the maximum MONTHLY amount you are able to invest at this time?

If granted a partial scholarship, it's important to Sarah and the Innergize Team, that you are committed to yourself and this program and will do your best to make the live calls and participate fully in the program. What is your level of commitment at this time to yourself and this program? *

100% committed

80% committed

50% committed

20% commmitted

Other:

Thank you! Applications will be reviews on a rolling basis. You will be contacted via email to inform you of the outcome of your application.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Sarah Speers. Report Abuse

Forms