Healing Heroes

Scholarship Application

Most of our scholarship recipients have been selected because they took the time to share their stories and provide thoughtful, detailed responses. The more you share, the better we can understand your needs and support your journey. Thank you for trusting us with your story!

Are you Military or First Responder? *

Military (Active Duty or Veteran of the U.S. Armed Forces)

First Responder (Firefighters, Law Enforcement Officers, Emergency Medical Technicians (EMT), Paramedics, Federal Agents)

Both, Military and First Responder service

What was your Military Occupational Specialty (MOS)? *

How many total years did you serve in the military, law enforcement, or as a first responder? *

Dates & location of combat deployments (if applicable) *

Was your injury or condition related to your service? *

Yes, during combat deployment

Yes, injured in line of duty (non-combat)

No, not service-related

Upload Proof of Service: Military: DD214 (for security purposes black out social security number) *

PDF, PNG, JPEG or JPG

Upload First Responder Proof of Service: Submit your Service ID and a verification letter that includes years of service. If retired, the letter must indicate left in good standing. *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Total Disability Rating *

Individual VA Disability Rating(s) *

If diagnosed with cancer in last 5 years, explain *

Tell Us Your Story (Minimum 100 words) *

This is your opportunity to help the scholarship committee truly understand your journey. Please share in detail how your service has shaped your life, describe your pain, the ways your injuries or health challenges have impacted you, and why you are seeking support at this time. Thoughtful, detailed responses are essential to our selection process.

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

We’d love to hear how receiving a scholarship from the Miracle Hope Foundation would make a difference for you—whether in your healing, daily life, or future goals. The more you share, the better we can advocate for you.

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

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

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

Current Dietary Habits *

Very Healthy

Moderately Healthy

Could Be Healthier

Do you currently drink alcohol? *

Socially (1-3 per week)

Daily for pain management

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

Yes

Did You Already Connect with a CPI Representative? *

Yes

If Yes, please provide their name: *

Have you received a CPI doctor call and received a treatment plan? *

Yes

Not Yet

Do you have a scheduled treatment date? *

Yes

Not Yet

Currently at CPI Facility Receiving Treatment

What are you looking to get a partial scholarship to cover? *

Additional IV Therapy

Additional Take Home Medication

Other

What other veterans organizations have you received support from? *

How Did You Hear About Us? *

Military Service acknowledgment *

I acknowledge I qualify for one of the following: Minimum of 6 years of service, OR A combat deployment, OR A service-related injury. Must be honorably discharged (if no longer active duty).

First Responder Service Acknowledgement *

I acknowledge meet one or more of the following criteria: I have served as a Firefighter, Law Enforcement Officer, Emergency Medical Technician (EMTs), Paramedic, Federal Agent for a minimum of 6 years of service, OR injured in the line of duty. Must have ended service in good standing.

Treatment Acknowledgement *

I acknowledge that participants must be qualified for treatment with an approved provider. I understand that the medical provider requires a $2,500 fully refundable deposit to schedule a doctor consultation to receive an approved treatment plan.

Financial Acknowledgement *

I confirm that I am applying because I have a true financial need.

Privacy Rights *

I consent to the release of my confidential health information, including relevant records and details about my health status or treatment to Miracle Hope Foundation. This information is shared solely for purposes of scholarship and treatment process, research and study data collection. I understand this consent is voluntary and may be revoked in writing at any time.

Terms & Conditions *

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

Once you submit this form, you’ll be redirected to our military & first responder verification form. Please complete the form to proceed to the next step in the process. Thank you!