Organization Contact Information

Organization Name

100 characters

Organization Address

Organization City

Organization Country

Organization State

Organization Province

Organization Postal Code

Organization Website

100 characters

Applicant Contact Information

Applicant Name

25 characters

Applicant Email

Applicant Direct Phone

Applicant Extension

Applicant Fax

Applicant Address

Different than Organization

Applicant Address

Applicant City

Applicant Country

Applicant State

Applicant Province

Applicant Postal Code

Administrator Contact Information

Administrator

Different than Applicant

Administrator Name

25 characters

Administrator Email

Administrator Phone

Administrator Extension

Administrator Address

Different than Organization

Administrator Address

Administrator City

Administrator Country

Administrator State

Administrator Province

Administrator Postal Code

Other Contact Information

Name and title of person responsible for integrating FitSteps for Life into your organization (Answer "Unknown" if this person isn't in place yet)

25 characters

Direct Phone

Extension

Organization Structure

Number of oncologists on staff

Numbers only - 10 characters

Number of oncology patients served per year

Numbers only - 10 characters

Geographic area served

100 characters

Mission | Alignment

Provide a brief, relevant history of your organization

500 characters

Summarize your goals, mission, and vision

500 characters

Explain how your mission and vision align with Cancer Foundation For Life's mission to enhance the quality of life and survival for individuals living with cancer and its vision to incorporate individually tailored and supervised exercise programs as a standard of care in oncology practice?

2500 characters

Describe your interest, if any, in using FitSteps for Life as a resource for research

1100 characters

Space | Equipment

Do you have an existing facility that could accommodate FitSteps for Life?

YesNo

Describe the size of the space allocated to providing FitSteps for Life (minimum 600 sq. ft.)

500 characters

List any existing equipment in your facility you would specifically dedicate to providing FitSteps for Life

500 characters

What space do you have available to accommodate FitSteps for Life (minimum 600 sq. ft.)

500 characters

Describe potential opportunity, if any, to expand FitSteps for Life to additional locations within your organization (i.e. wellness centers or satellite locations,) including the geographic location of those facilities

500 characters

List the hours during the week when you would be willing to provide FitSteps for Life (i.e. Monday-Friday, 8am-3pm)

50 characters

Staff Requirements

The FitSteps for Life program must be administered by individuals degreed in Exercise Science. ACSM CET certification is preferred. Do any current staff meet these requirements?

YesNo

List how many individuals and their qualifications

100 characters

Are you willing to fulfill these staffing requirements if awarded funds?

YesNo

Successful Partnership

If selected to receive funding to incorporate FitSteps for Life into your organization, describe your ability to independently sustain FitSteps for Life for a minimum of 5 years

2500 characters

What marketing resources are utilized in your organization and how would you incorporate FitSteps for Life into your marketing strategy for program sustainability?

2500 characters

What other ideas for partnership do you have?

1500 characters

Attachments

Upload FitSteps for Life project budget

Upload letter signed by oncologists acknowledging the benefit of exercise treatment and their commitment to support FitSteps for Life

Upload most recent Form 990

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