Scholarship Request Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Birthdate * MM DD YYYY Gender * Ethnicity * Asian Black / African American Hispanic / Latinx Native American Pacific Islander SWANA White / Caucasian Additional Identity (fill in below) Prefer not to answer Additional Identity Affiliation / Profession * Are you a student? * Yes No If yes, name of school / program What percentage of scholarship would you need to be able to participate? * 25% or less 50% or less 75% or less Pay-what-you-can monthly payments Please select the course of interest * The Embodiment Project Professional Embodiment Training In-Person Manual Therapy Virtual Embodiment Coaching Please write a brief statement (250 words max) describing your interest in this course or service and why you would benefit from receiving scholarship funds. * Thank you!
