GRIT Application | QLI

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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 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

Let’s Talk!

Choosing the best place to recover from catastrophic illness or injury is not only challenging, it is crucial. Let us provide you the information you need to make the right decision. Contact us with any question today.

Contact ADMISSIONS

QLI@QLIomaha.com

6404 N 70th Plaza
Omaha, NE 68104

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