REC & FIT Scholarship
Request Form
Applicant Information
Salesforce Program Relationship
Patient Name
*
First Name
Last Name
Name of person filling out application if for a minor
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Patient Date of Birth
*
-
Month
-
Day
Year
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May CDF provide you with updates and mailings?
Yes, subscribe me to this newsletter.
Do you confirm, under penalty of perjury, that the person stated above has been diagnosed with cystic fibrosis?
*
Yes
May CDF use your photographs, application, questions, responses, thank you notes, etc, to help demonstrate the impact of our programs to the public on the CDF website and or social media channels?
*
Yes
No
Complete this section if the applicant is a minor
Otherwise, continue to the next page.
Open this section if the applicant is a minor
Guardian
First Name
Last Name
Relationship to Applicant
Email
example@example.com
Phone Number
Please enter a valid phone number.
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Media Release
I give permission to the Cody Dieruf Foundation [CDF] to publicize my, or my child's, photographs, application responses, and other forms of communications for marketing and outreach purposes. I understand these purposes may include physical publications in print advertising, appeal letters, flyers, and/or brochures as well as digitally on our website and social media accounts. I further understand that this release is optional, and that I may refuse by not signing below.
Applicant or Guardian's Signature
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Activity Information
If you are applying for an activity such as sports or classes, please complete the section below. Be as specific as possible so that we may accurately process your request.
Open this section to apply for a fitness activity or program
Are you applying for a class, membership, or equipment? Please state the full request below:
Program & or equipment name(s)
*
Start Date
-
Month
-
Day
Year
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Total Duration
Program Contact if applicable
*
First Name
Last Name
Program Email if applicable
*
example@example.com
Program Phone Number if applicable
*
Please enter a valid phone number.
Total Cost
*
Program or activity Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you signed up for this activity/class/pass/membership already and signed the release forms?
*
Have you already paid and need reimbursement or do we need to contact the program to make payment?
*
Emergency Contact
*
First Name
Last Name
Emergency Contact's Relationship to Applicant
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Emergency Contact email:
example@example.com
Product Information
If you are applying for a product, such as exercise equipment, please email the specific link or links to pam@breathinisbelievin.org
Open this section to apply for a fitness product
Product Name
Product Description
Email links of desired equipment to pam@breathinisbelievin.org
Total Cost
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Photograph & Personal Statement
Please attach a recent photograph of yourself or the applicant. If you have received the REC & FIT scholarship in the past, please include a photo of that activity.
Upload here
*
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Briefly describe the image submitted
*
Include details about the activity being performed.
In roughly 500 words, please describe how this scholarship will benefit you.
*
You may describe how you believe your request will improve your ability to manage your cystic fibrosis or mental health. Why did you chose this request? You may also describe how your previous exercise has improved your lung function, and if you believe this request will improve your strength, confidence, and overall sense of fulfillment.
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Contract of Agreement
Please read each of the statements below. Upon agreeing to these conditions, please sign using the field below.
I understand I am undertaking the activities requested in this application under my own (child's) risk and will not hold CDF nor any of their partners liable for any injury or negative health impact related to this activity.
*
I agree
I understand the spirit of these funds is to help improve my lifestyle, which includes my physical, emotional, and social well-being. I will do my best to use this scholarship to improve my life, and to use it toward on-going activities that I believe to be beneficial to my health.
*
I agree
I will not sell, trade, or profit from any goods or services rendered from this scholarship.
*
I agree
I will update CDF with any contact information changes such as my address, email, or phone number.
*
I agree
Applicant/Guardian's Signature
*
By signing you state that you have read, understand, and agree to all of the above statements.
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Physician's Endorsement
To utilize this program, you must have received an endorsement of your health and physical capacity from your physician using our REC & FIT Physician's Form. You can download the physical form at www.breathinisbelievin.org > Programs > REC & FIT > Physican form.
Upload Physician's Form
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Choose a file
This can be a photograph of the form or a formal scanned document. If you are unable to upload your form today, you can email it to contact@breathinisbelievin.org instead. Your request will not be processed until this form is submitted.
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