Application Due by October 17, 2016

See Scholarship Guidelines for Policies and Criteria

Tai Chi for Health Community
2017Workshop Tuition Scholarship Award Application
______

SECTION 1: APPLICANTINFORMATION

Name:

I am a member of the Tai Chi for Health Community. TCHC Member ID#______

(Your member ID# is available in your member profile on the TCHC website – To be eligible for a scholarship, you must be a current member of the Tai Chi for Health Community. To become a member, go to

Contact Email Address:

(Personal email preferred, business addresses may not accept group emails)

Home Address:

Phone number:

When did you begin your tai chi journey? (Approximate year)

Which style or form did you first learn?

What other styles or forms have you learned since then, if any?

SECTION 2: WORKSHOP INFORMATION

1)Class Preference for2017 June Workshop______

Typical class choices: Yang 24, Depth of Yang 24, Sun 73, Depth of Sun 73, Chen 36,Depth of Chen 36, Yang 40, Tai Chi for Energy, Combined 42 forms, Fan, Sword, Push Hands, Silk Reeling – Class selections vary slightly year to year.

2) Tai Chi for Health Certifications; Check All That Apply
Please check the appropriate boxesfor the tai chi programs you have completed and are certified in:

Tai Chi for Arthritis 1 Tai Chi for Arthritis 2

Tai Chi for Diabetes Tai Chi for Beginners

Tai Chi for Back Pain Tai Chi for Osteoporosis

Tai Chi for Kidz Tai Chi at Work

Qigong for Health Tai Chi for Falls Prevention

Dr. Lam’s Yang 24 Dr. Lam’s Yang 24 in depth

Dr. Lam’s Sun 73 Dr. Lam’s Sun 73 in depth

Tai Chi for Energy Tai Chi for Rehabilitation

Seated Tai Chi for Arthritis No Tai Chi for Health programs completed

What interests you about attending this workshop? (A brief explanation of 150 words maximum)

SECTION 3: EXPERIENCE AND INTEREST IN TAI CHI AND THIS SCHOLARSHIP

Have you taught tai chi for health courses? Yes ___ No ___

Write a brief description about what teaching Tai Chi for Health means to you.

Please list volunteer or community service activities in which you have been involved.(No more than 5 of most recent)

Describe your interest in promoting Tai Chi for Health programs.

Are you a Senior Trainer? Yes ___ No ____

If so, how long have you been a Senior Trainer? ______

List trainings, skills workshops, and instructor support you have organized in the past 2 years.

Please provide a brief description (200 words or less) about your reasons for applying for financial assistance. Please understand that scholarships will only cover workshop tuition. Housing, meals, and transportation will not be covered.

SECTION 4: REFERENCES

Please provide one written reference along withthe email address of theperson providing the reference. The person writing the reference should be a Master Trainer or Senior Trainer who can address the following:

  1. Your seriousness of purpose to teach tai chi for health, and
  2. Your ability to relate and work with people

If a Master Trainer or Senior Trainer is not available to provide this reference, it needs to come from an individual associated with the Tai Chi for Health Institute.

[ enter reference's name and email address]

Affirmation and Consent to Publicity

Check boxes that apply:

I attest that my information provided is true and I accept the TCHC Scholarship policies, terms and guidelines

(Box 1 must be checked for a valid application.)

I understand that this is a tuition scholarship and will cover approximately 1/3 of the total cost of the workshop. Room and board and travel expenses are not covered by this scholarship.

(Box 2 must be checked for a valid application

I consent to TCHC media publicity, interviews, news releases and the use of my name and photograph. (Publicity about applicants and awards helps TCHC generate interest and support for our scholarship program.)

[ type name ] [ type date ] ____________

Electronic Applicant Signature Date [ MM/DD/YYYY ]

Send completed application to , by October 17, 2016.

Application: 2017 MS Word Fill In version Page 1 of 4