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Click here for the latest on QLI’s COVID-19 precautions.
Home
About QLI
About QLI
Team
Admissions
About Omaha
Accommodations
Campus Tour
Frequently Asked Questions
Funding
Programs
Brain Injury
Spinal Cord Injury
Stroke
Chronic Pain
Ability Assessment
Limb Loss
GRIT
Telerehabilitation
Resources and Learning
Resources by Diagnosis
Webinars & E-Learning
Thought Leadership
Contact
Guts. Resilience. Intensity. Tenacity.
GRIT Adaptive Fitness Application (next session starts October 15th, Tuesdays & Thursdays) **Program cost will be discussed via email or phone call after the application is completed. Scholarships are available and will be determined by application process. **
Full Name
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Email
Emergency Contact
*
Relationship
*
Emergency Contact Phone
*
Injury Type
*
Mobility
*
Wheelchair
Walking Device
Independently Ambulatory
Other Adaptive Needs/Restrictions (i.e. AFO, Gripping Devices, Wristbands, etc)
Goals for participation in GRIT Gym
*
Are you currently employed?
*
Yes
No
If yes, please list current employer and length of employement
Salary/Wage (*If applying for intent of scholarship)
If no, is future employment a goal?
Yes
No
Are you a military veteran?
*
Yes
No
Have you ever been charged with a violation of the law that resulted in, or if still pending could result in, probation, community service, a jail sentence, or the revocation or suspension of your driver’s license? (Note: May not exclude you from participating in the program)
*
Yes
No
If yes, please explain
I certify that my answers are true and complete to the best of my knowledge. If this application leads to a financial assistance scholarship, I understand that false or misleading information in my application may result in my release from the program.
*
Agree
