Grand Rapids CoHort Applications

Starting Line Scholarship

Please fill out the information as truthfully as possible to be considered for a Starting Line Scholarship from Still I Run and The Well Being. All information you share with us will remain private and will only be used for consideration purposes. When filling this form out, please take your time as we will be evaluating your answers to see if you are a good fit for the program.
Before You Begin

This program is open to anyone in the West Michigan area since the program requires two in person meet-ups a week for 10 weeks. We are specifically looking for individuals who are not experienced runners (or it’s been a while since you’ve run and need help getting back into it) and are currently struggling to some degree with your mental health. You must also be interested in utilizing running as a tool to help improve your mental health, and able to commit to attending the fitness classes and group runs every week for 12 weeks.
Part I: General Information
Name*

First NameLast Name
Age*
Which of the following best describes you?*
Please indicate your gender identity/expression*
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Were you referred to this program by a physician or another organization?*

YesNo
What is the name and contact information of the referring physician or organization?*
Just put N/A if not applicable.
Part II: Physical Activity Readiness
What is your experience with running so far?*
Please explain in 1-3 paragraphs. The more detail the better.
Have you ever run a race before?*

YesNo
Do you have medical clearance for your primary care physician or medial professional to join this program?*

YesNo
How would you currently rank your ability to walk a mile on a scale of 1 to 5? (1 meaning you cannot walk a mile yet and 5 meaning you can easily walk a mile)

1

2

3

4

5

1 is , 5 is
Do you believe it is within your capabilities to run at least a portion of the 5K race at the end of the program?

YesNoUnsure
Please note: For safety reasons, participants in the 5K race at the end of the program must maintain a pace of at least 15 minutes per mile.
Part III: Deeper Dive
Why do you want to be a part of the Starting Line Scholarship with Still I Run and the Well Being? Why is this important to you?*
For this question we would like you to share a paragraph or two about how this would explicitly help your mental health, moreso than your physical health.
Have you ever been diagnosed with a mental health condition?

YesNoI don't wish to share that information
What barriers have you encountered in the past (or are dealing with now) that have kept you from running for your mental health?*
Please explain in 1-3 paragraphs.
Part IV: Expectations

As a part of this program, you are expected to attend two meetings a week for 10 weeks with Still I Run and The Well Being. The program kicks of February 27 and ends with a 5K on May 11.
Are you able to commit to attending the Wednesday Night Fitness Class/Support Group from 5:45 - 7:15 pm every week for 10 straight weeks?

YesNo
In addition to the Wednesday Night class, are you able to commit to attending the Saturday morning group runs from 8:30 am to 9:30 am every week for 10 straight weeks?

YesNo
Are you comfortable with being photographed and/or recorded for marketing purposes?

YesNo
Good work! You're finished! Just press the submit button below and we'll be on our way.

You'll hear back from us either way once the application period closes.
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Starting Line Scholarship

Before You Begin

Part I: General Information

Part II: Physical Activity Readiness

Part III: Deeper Dive

Part IV: Expectations