Page 1 of 1
Modern Pain Pro Scholarship Application
Section 1 - Applicant and Professional Background
Full name:
*
Email address
*
Country of Residence
*
Primary profession (physiotherapist, occupational therapist, MD,..other)
*
Years of experience
*
Section 2 - Interest & Alignment
Why are you interested in joining the Modern Pain Pro
*
How do you see this program benefiting your patients or community?
*
What specific challenges do you currently face in managing complex pain cases?
*
Have you completed any training in psychologically informed care, ACT, or pain neuroscience education?
*
Have you completed any training in psychologically informed care, ACT, or pain neuroscience education?
No
Yes
Please specify
*
Financial Need
Do you have access to employer or institutional funding for continuing education?
*
Do you have access to employer or institutional funding for continuing education?
Yes
No
Briefly explain your financial situation and why a scholarship would make participation possible for you (responses are confidential)
*
Would you be able to contribute a partial payment toward the program if awarded a partial scholarship?
*
Would you be able to contribute a partial payment toward the program if awarded a partial scholarship?
Yes
No
Section 4 - Commitment & Impact
How will you apply what you learn to improve pain care in your local community?
*
Are you willing to share your experience and results as a case study or testimonial to help others learn?
*
Are you willing to share your experience and results as a case study or testimonial to help others learn?
Yes
No
How did you hear about this scholarship opportunity?
*
How did you hear about this scholarship opportunity?
Instagram
Email
LinkedIn
Podcast
Referral
Section 5 - Agreement
If awarded, do you commit to completing all modules, participating in live sessions, and engaging with the community?
*
If awarded, do you commit to completing all modules, participating in live sessions, and engaging with the community?
Yes
No
Signature / date
*
Signature
Submit
