Dr Heather Gansel is committed to supporting equitable access to wellness and professional development. Completion of this form is optional but helps us allocate scholarship resources to those with demonstrated financial need.

All information will be kept confidential.

Disclaimer:
This scholarship applies exclusively to the 3-Week Virtual Sports Chiropractic Program—Dr. Heather’s signature course that has helped thousands of runners eliminate pain in under three weeks. Please note: If accepted into the scholarship program, there are no refunds or makeup sessions for any missed appointments.

First Name *

Last Name *

Phone *

Date of birth *

Address *

Street Address

City

State

Country

Postal code

Email *

Please complete the following questions to be considered for the Ask Doctor Heather

Scholarship.

Are you a citizen of the United States? *

Have you ever worked with Dr Heather before? *

If yes to the above question please indicate when below *

Why are you interested in participating in the 3wk Virtual Sports Chiropractic Program? *

Are you able to attend six (6) 30-minute Zoom sessions over the course of 4 weeks? *

Are you willing to complete short, customized exercise assignments between sessions to improve your results? *

Financial Questions must be answered below

Monthly Household Income (after taxes): *

Number of people supported by this income (including yourself): *

Briefly describe your current financial situation and why you are requesting this scholarship: *

Do you currently experience any of the following financial burdens? (Check all that apply) *

Significant student loan debt

Medical expenses not covered by insurance

Supporting dependents (children, elderly, disabled family)

Living paycheck to paycheck

Recent loss of income or hours

Other: _______________________________

Are you willing to provide supporting documentation if requested (e.g., pay stub, student loan statement, proof of dependents)? *

If selected, do you agree to participate in good faith and understand that failure to engage in homework may disqualify you from the scholarship? *

Are you willing and able to commit to attending all sessions and completing the assigned homework exercises? *

Disclaimer and signature

I certify that my answers are true and complete to the best of my knowledge.

Participation in the 3 wk Virtual Sports Chiropractic Program is voluntary and provided as a wellness opportunity. This program is not a substitute for medical care, diagnosis, or treatment by a medical professional. Any health-related information disclosed during the program is confidential between the participant and the provider.

Participants are encouraged to consult their personal healthcare provider before beginning any new exercise or treatment program. Dr Heather Gansel reserves the right to modify or terminate the scholarship offering at any time. There are no refunds for this program and missed sessions may not be rescheduled.

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