"Reps4Resiliency" Client Program Application

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* 1. Hello! We're so happy you are applying to participate in our 2021 Reps4Resiliency Victorious Program. We can't wait to help you reach your health and fitness goals! First, please let us know if you are filling this application out for yourself or nominating a client?

Nominating a candidate.

Applying for myself.

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* 2. Great! Please let us know who is this wonderfully resilient person wishing to be a part of our program is and how can we best reach them?

Name *

City/Town

State/Province *

Email Address

Phone Number *

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* 3. Are you currently, or have you recently been a client of the following? If none apply, you can leave this question blank.

Rose Brooks

Hope House

New House

Mattie Rhodes

Sunflower House

Veronica's Voice

Safe Home KC

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* 4. How did you hear about this sponsorship program?

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* 5. Are you currently involved in a fitness program or have a membership already at a gym facility?

Yes, I have a current gym membership.

No, I do not have a membership set up anywhere.

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* 6. Can you briefly share with us how this sponsorship program would positively impact your health and fitness goals and why you feel you'd make a prime client for this program?