Tai Chi & Qi Gong as Complementary Medicine Application Name * First Name Last Name Are you a parent or guardian applying for a minor? * Yes No If you are a parent or a guardian applying for a minor, please state the name(s) and age(s) of the child or children for whom you are applying I am applying for: 3-Month Sponsorship 6-Month Sponsorship Year-Long Sponsorship Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How many people are in your household? * What is your combined monthly countable household income? * Please check only one option. $0.00-$2,000.00 $2,000.00-$3,000.00 $3,000.00-$4,000.00 $4,000.00-$5,000.00 $5,000.00-$6,000.00 $6,000.00-$7,000.00 $7,000.00 and above Do you and your dependents qualify for MediCal or MediCare/ * If so, you'll be asked to provide proof. Yes No Do you and your dependents qualify for SNAP benefits * If so, we will request proof of qualification. Yes No Please share the amount of money that you are able to contribute, monthly, to the Tai Chi training. * Do you, or does anyone in your household, have a disability? * Yes No Are you, or is anyone in your household BIPOC (Black, Indigenous, Person of Color)? Yes No What are you experiencing in your health that indicates the need for Tai Chi & Qi Gong as Complementary Medicine? * What are your specific goals for the program in terms of health benefits? * Thank you! Learn More About the Sponsorship
