Healing Heroes Treatment Scholarship Interest Form

First Name *

Last Name *

Phone *

Email *

Age *

State *

Timezone *

Pacific Standard Time (PST)
Mountain Standard Time (MST)
Central Standard Time (CST)
Eastern Standard Time (EST)
Other
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Are you Military or First Responder? *

Military

First Responder

What Classification? *

Firefighter
Police Officer
Emergency Medical Professional
FBI
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Which Military Branch? *

Air Force
Army
Coast Guard
Navy
Marines
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Upload Proof of Service: Military: DD214 (for security purposes black out social security number), or First Responder: Service ID or Department Verification Letter *

Annual Income *

Less than $75,000
$75,001-$125,000
$125,001-$175,000
Greater than $175,000
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Which treatments or therapies have you used to treat your injuries? *

Total Disability Rating *

Individual VA Disability Rating(s) *

What other veterans organizations have you received support from? *

Share How Receiving This Scholarship Will Change Your Life. *

Be as detailed— this section is key to our scholarship committee selection process.

Tell us about why you are seeking stem cell therapy *

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

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

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

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10
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What specific improvements or outcomes you hoping to achieve through receiving stem cell treatment? *

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

Yes

If diagnosed with cancer in last 5 years, explain *

Current Dietary Habits *

Very Healthy

Moderately Healthy

Could Be Healthier

Do you currently drink alcohol? *

Socially (1-3 per week)

Daily for pain management

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

How Did You Hear About Us? *

Acknowledgements

Scholarship Acknowledgement *

I acknowledge participants must be qualified to receive treatments with qualified provider

Financial Acknowledgement *

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

Privacy Rights *

I consent to the release of my confidential health information, including relevant records and details about my health status or treatment, by the custodian of records and staff of Miracle Hope Foundation. This information may be shared solely for purposes related to the scholarship and treatment process. 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 text from Miracle Hope