Breast Cancer :: Pilates Scholarship

First Name:    Last Name:
Address:     City:    
State:    Zip:
Age:
Phone:
Email:
Date of diagnosis:
What treatment have you received to date?

When did your treatment discontinue (if it it not ongoing)?

Do you have any previous experience with Pilates? Yes: No:
If 'Yes,' please describe your experience:

How would you characterize your daily level of activity?
Sedentary Light Moderate Very active
Please select one of the following to describe your current level of fitness:
Deconditioned Somewhat fit Fit Very fit
Will you be able to attend all sessions (Saturdays, 12-1PM) from November 7th to December 19th, 2009?
Yes: No:
Please tell us why you are you interested in this scholarship:


Send us your application: