FULL PRICE CHECKLIST:

If most of the following are true, I can likely pay full price and may not need full financial support.

I am able to meet my basic needs (food, housing, transportation).

Although it might be tight, I am able to spend some of my income on fitness, shopping, travel, entertainment, or eating out.

I am able to pay my rent, or I own my home or property.

I am employed.

I have attended or currently attend higher education.

I have access to financial support through family, savings, or other resources in times of need.

FINANCIAL SUPPORT CHECKLIST: *

If any or all of the following are true, I should request financial support.

I would like to be active but spending money on fitness is not an option because it would produce genuine financial hardship.

I am sometimes unable to meet my most basic needs.

I am accruing credit card debt in order to survive.

I do not have access to financial support from other resources, such as a partner’s income, family, or investments.

I have a disability that impacts my ability to work/earn money.

I live in a NYCHA building.

I am on food stamps.

I am on Medicaid.

I have self screened and feel this program is appropriate for my situation. *

Yes

No

Name *

First Name

Last Name