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* 1. Contact and Background Information

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* 2. Briefly describe areas where the applicant is struggling socially and/or emotionally. For example, insecurity, low self-esteem, anxiety, depressive feelings, or other areas.

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* 3. Please rank on a scale of 1 (not at all relevant) to 7 (extremely relevant) how the applicant struggles in the below areas.

  1 2 3 4 5 6 7
Anxiety/Worry
Depression/Sadness
Low self-esteem
Anger
Physical aggression, such as hitting or throwing things
Perfectionism
Dislike of self
Self harm, such as cutting
Suicidal thoughts
Suicide attempts

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* 4. What is the applicant hoping to gain from this program?

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* 6. Are there any health issues that would prevent or hinder your participation in physical activity? If so, please explain.

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* 7. Financial Assistance: The cost of the program is $250. Please indicate if you need partial scholarship to be able to participate in the program. Please note there are limited scholarship funds available and while we hope to provide assistance to all those in need, that may not be possible. Please give your best estimate of scholarship amount needed to participate in this program.

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* 8. If requesting a scholarship, please tell us about your financial needs.

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