RLMI Scholarship Application

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

Scholarships to Rochester Lifestyle Medicine Institute's (RLMI's) programs are provided on an as-needed basis and when funding is available. RLMI is a 501(c)(3) nonprofit organization.

Please complete the questions below. You will be contacted after your application has been reviewed.

Thank you,

The RLMI Team

Note, signing into Google to save your progress is NOT required.

Email *

Your first name *

Your last name *

Your phone number *

What type of health insurance do you have? *

Are you currently employed?
*

Yes

Retired

If you are employed, what is your occupation?
*

Within the past 12 months, was there ever a time when the food you bought didn't last, and you didn't have the money to buy more?
*

Yes

In the past 12 months, has lack of transportation kept you from meetings, work, medical appointments, getting medications, or from getting things needed for daily living?
*

Yes

In the last 12 months, was there a time when you were not able to pay the mortgage or rent on time, or was there a time when you did not have a steady place to sleep or slept in a shelter (including now)?
*

Yes

Which RLMI program are you requesting a scholarship for? (If you are not familiar, please review the programs at RochesterLifestyleMedicine.org before proceeding with the application.) *

15-Day Whole-Food Plant-Based Jumpstart Program

The Lift Project

Required

Which program start date do you want to participate in? (The schedule of upcoming programs are listed on our website calendar.)

If you are applying for a Jumpstart scholarship, please check the requirements that you will be able to fulfill.

Complete the pre Day-1 and Day-15 questionnaires

Pre Day-1 and Day-15 bloodwork: lipid panel, fasting glucose, HbA1c (just once, if concerned about diabetes)

Provide us your health care provider's information (we share your results with them).

Send your provider a letter that we give you, informing them of your participation in the program.

I am not applying for the Jumpstart program (therefore, not applicable)

Required

How much will you be able to contribute towards the tuition fee?

If you would like a copy of this survey with your responses emailed to you, please click the slider below "Send me a copy of my responses." before clicking on the Submit button. The slider will move to the right and the circle will turn dark when turned on.

Click the Submit button to complete your application.

Thank you for filling out the application. Someone will be in touch with you soon.

In health,

The RLMI Team

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Rochester Lifestyle Medicine Institute. Report Abuse

Forms