Birth & Bloom Scholarship Application

2025 Scholarship Application for

Postpartum Physical Therapy Package

Provided by Birth & Bloom Physical Therapy
Purpose: We’re so excited to offer our postpartum physical therapy package (includes 6 visits) to a deserving postpartum mom! If you know a mom who could benefit from support, healing, and guidance, please fill out the form below to nominate her. You may nominate yourself :)

Reward: One applicant will be selected for the Birth & Bloom Postpartum package. This includes six (6) sessions with a Doctor of Physical Therapy. Each session will last approximately 45-60 minutes. Sessions are customiazble to meet the needs of the individual receieving care.

Qualifications: Candidates must meet the following criteria to qualify for this award:

- Vaginal or Cesarean delivery within the past calendar year

- Recipient must be located within New York State

*Application must be submitted by JULY 1, 2025 at 11:59pm.

Nominee Information
Full Name*

PrefixFirst NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Baby's date of birth (list estimated due date if nominee has not yet delivered)*
Why are you nominating this postpartum mom? Please tell us about any challenges this mom has faced and why you believe she deserves to receive this care service. (Feel free to include any personal stories, circumstances, or why you think this service will make a difference for her.)

Certification
By submitting this form, I confirm that I have obtained the nominee’s permission to contact them in the event they are chosen as the winner of this giveaway.
Signature (Please type your name)*
Date Completed

MonthDayYear
Should be Empty: