Healing Heroes Treatment Scholarship Interest Form

First Name *

Last Name *

Address *

City *

State *

Postal code *

Phone *

Email *

Are you Military or First Responder? *

Military

First Responder

What Classification? *

Firefighter

Police Officer

Emergency Medical Personnel

If Military, which branch? *

Air Force

Army

Coast Guard

Navy

Marines

Tell us why you should be chosen to receive a Miracle Hope scholarship *

Individual Household Income *

Less than $35,000
$35,000-$50,000
$50,000-$100,000
Greater than $100,000
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Total Disability Ranking *

Individual VA Disability Ranking(s) *

What other veterans organizations have you received support from? *

Which treatments, modalities, or therapies have you used to treat your injuries? *

Proof of Service: Upload Military ID Card, Service Record, VA Verification Letter or DD214 (For security purposes, block out social security number) *

How Did You Hear About Us? *

Medical History

Date of birth *

Weight *

Height *

Tell us about your current injuries (and surgeries if applicable) *

Medical History/Prescriptions *

Rate Current Pain level (where 1 is the lowest and 10 is the highest) *

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Rate Current Physical Activity Level (where 1 is not active, 10 is extremely active) *

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Do you avoid any activities due to pain or discomfort? If so, which ones? *

Rate Quality of Life (1 is very poor and 10 is excellent) *

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What specific improvements or outcomes in your life are you hoping to achieve through receiving stem cell treatment? *

Have you been diagnosed with cancer in last 5 years? *

Yes

No

If diagnosed with cancer in last 5 years, explain *

Current Dietary Habits *

Very Healthy

Moderately Healthy

Could Be Healthier

Do you currently drink alcohol? *

No

Socially (1-3 per week)

Daily for pain management

Did You Already Connect with a CPI Representative? *

Yes

No

If Yes, please provide their name: *

Acknowledgements

Scholarship Acknowledgement *

I acknowledge participants must be qualified to receive treatments at CPI

Financial Acknowledgement *

If awarded partial treatment scholarship, I acknowledge I will be able to pay for or fundraise for the remaining balance of my stem cell treatment

Terms & Conditions *

Yes! I want to receive updates from MHF and agree to receive communication via email and text from Miracle Hope

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