Healing Heroes Treatment Scholarship Interest Form

First Name *

Address *

Last Name *

City *

Phone *

State *

Email *

Postal code *

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 *

Medical History/Prescriptions *

Injuries and Surgeries *

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 scholarship recipients 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