Cancer Awareness Scholarship Campaign Form

Cancer Awareness Scholarship Campaign Form

Open to both cancer survivors or those who are currently fighting cancer.

Upload of physician clearance is required.
General Info:
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Currently RecPlex member?
How do you feel being part of our Personal Training Scholarship Program would benefit you?
How did you hear about the program?
Medical Info:
Age
Diagnosis
Year of Diagnosis
Name of Oncologist/General Practitioner
Explain Treatment and Year of Treatment
Describe Current Physical Level
How often are you able to workout?
Should be Empty:

General Info: