Step 1: Complete Parent Form

The purpose of this program is to help children and adults reach their health, fitness and athletic goals by subsidizing the fees associated with their chosen sport and other related activities.

Stipends will be paid directly to the organization hosting the athletic activity. This stipend is awarded with expectation that your child will remain enrolled in this activity for at least the duration of the season or time specified in your application. Barring extenuating circumstances, we strongly discourage withdrawing your child from the activity in which (s)he is participating. Should you choose to withdraw your child and you do receive a full or partial refund of the registration fees and or other expenses that were covered by Health Quest Solutions, Inc stipend, we request that those funds be returned to Health Quest Solutions, Inc immediately so that they can be used to subsidize the athletic and fitness goals of another child in need of reaching specific athletic or fitness goals.

Thank you for your commitment to keeping our children healthy and fit!

  This form can only be filled out by parents or guardians.   

All fields required unless otherwise stated

Applicant's Name

Address

Email Address

Daytime Phone Number

Evening Phone Number

Name of Parent/Guardian

Date of child's birth

How is your child’s overall health and well being?

Is your child currently involved in sports (other fitness related activities)? Please describe his/her previous involvement in athletic activities?

Has your child’s physician expressed any concerns about your child’s health or fitness level? How will your child’s participation in athletics enhance his/ her lifestyle?

Please list the athletic activity (ies) for which you are seeking this stipend

Name and contact information of Organization/Church Group/ Athletic Association sponsoring the activity:

How long will your child be involved in this sport/activity?

Please list all the expenses associated with this sport / activity:

Registration:

Uniforms: (if not included in registration fees)

Equipment: (If not included in registration fees)

Other:

Total Amount Requested:

I certify that the information entered on this form is complete and accurate.

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