Your Scholarship Registration

Please complete this form to register. We're excited to have you!

First Name

Last Name

Email *

City

Phone *

State

Are you experiencing any of the following challenges? Choose one or more.

Difficulty sleeping or disrupted sleep patterns?

Persistent feelings of anxiety or overwhelming stress?

Ongoing depression or pervasive feelings of sadness?

Emotional or mental health concerns affecting your daily life?

Other

Specify the percentage of scholarship funding you are applying for.

50%

75%

90%

Describe the motivations and aspirations driving your interest in this scholarship, and how it will support your academic or career objectives.

Emergency Contact

Full Name of Emergency Contact

Preferred contact method

Call

Zoom

Text

Email

Please share where you found us 🙂 *

Google Search

Social Media

Referred by a friend

Other (add to message below)

By checking this box, I agree to terms & conditions provided by the company and acknowledge and agree to participate in case study questions to support research for the Living Life Purple Foundation and to complete the intake form.