Heroic Hands: Women Veterans Scholarship Application Form

Scholarship Application Form

Application Deadline - November 30, 2024
Read and follow the instructions carefully prior to submitting your application. All winners will be notified on or before the 15th of December 2024.
I. Personal Data

Tell us about yourself
Full Name*

First NameLast Name
Birthdate*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
ex: Sarasota or Manatee
Mobile No*
Email *
Where the confirmation email will be sent to
What is your current occupation?
or Retired, Disabled, Student
Do you have children? If so, how many?
What is your highest level of education?

High School Diploma / GEDSome CollegeAssociate DegreeBachelor DegreeMaster DegreeDoctorateTechnical Training
II. Veteran Status
Please check your veteran status.*

VeteranChild of a VeteranGrandchild of a VeteranSpouse of a VeteranParent of a VeteranNone of the Above
Branch of Service*
Which years did you serve?*
ex. 2009-2013
Did you deploy?*

YesNo
If yes, where did you deploy to?
Are you a service-connected disabled veteran?*

YesNo
If you are service-connected disabled through the Veterans Benefits Administration (VBA), what is your current rating?
ex: 70%
Would you like to share with us the nature of your current disabilities?
Did you experience any Military Sexual Trauma (MST)?*

YesNo
If you are not currently service connected, would you like more information on how to get access to the help that you need?

YesNo
Can you tell us about your military service experience and any specific challenges you've faced that led you to seek holistic wellness support?*
Proof of Veteran Eligibility

Upload your DD214 with SSN removed.
Cancelof
III. Health Information
Do you have a primary care provider?*

YesNo
Do you have any physical conditions that should be considered when receiving massage therapy or bodywork services (e.g., chronic pain, injuries, surgeries, or medical conditions)?*

0/300
Are you currently receiving medical treatment for any physical or mental health conditions? If yes, please describe. *

0/300
How do you believe holistic wellness coaching and bodywork can support your personal and emotional healing journey?*

0/300
What specific outcomes or improvements are you hoping to achieve in your well-being during the 12-week program?*

0/300
Have you tried any wellness or self-care practices before? If so, which ones, and how did they impact you?*

0/300
IV. Coaching Services
Have you received coaching or holistic wellness consulting services before?*

YesNo
If yes, when and where?
What specific areas would you like to focus on in coaching?*

Stress ManagementAnxiety and DepressionGoal SettingCareer DevelopmentRelationship SupportPhysical Health & WellnessConfidence BuildingOther
What are some of the key challenges or personal goals you’re currently working through in your life?*
How would you describe your approach to self-care, and what areas do you feel could benefit from additional guidance?*
In what ways do you feel your past experiences have shaped your goals and intentions for the future?*
V. Income
Please indicate your yearly household income range:*

Under $30,000$30,000 - $40,000$40,000 - $50,000$50,000 - $60,000$60,000 - $70,000$70,000+
How many dependents do you have?*
How many of them are under the age of 18?*
Are you a single parent?

YesNoIt is complicatedOther
Do you receive any of the following benefits?*

Food StampsDisability BenefitsUnemploymentMedicaid / MedicareChildcare AssistanceHousing AssistanceOther, please specifyNone
If you do not receive any of the services, are you interested in learning more about any of the following:*

Food StampsDisability BenefitsUnemploymentMedicaid / MedicareChildcare AssistanceHousing AssistanceOther, please specifyNone
VI: Motivation and Commitment
How would you describe your approach to self-care, and what areas do you feel could benefit from additional guidance?*
In what ways do you feel your past experiences have shaped your goals and intentions for the future?*
VII: Future Impact and Community Involvement
How would receiving this scholarship impact your life and possibly the lives of others around you?*
Would you be open to sharing aspects of your journey to inspire other women veterans facing similar challenges?*
VII: Quality of Life Survey

Gives us a gauge of where you are currently at, at the moment you apply for the Scholarship Program. We are looking for a snapshot in this moment. Please fill it out to the best of your ability. Don't think too hard about a question, feel it in your gut and move on.

Scale: 1-10, with 1 being VERY POOR and 10 being EXCELLENT. 1 = never, 5= sometimes, 10 = very often

	1	2	3	4	5	6	7	8	9	10
Overall, how would you rate your quality of life?
How satisfied are you with your overall health?
In the past week, how often did you feel calm and relaxed? (0 = never, 5 = sometimes, 10 = very often)
How would you rate your physical pain or discomfort level? (1 = no pain and 10 = severe pain)
How would you rate your energy levels on a daily basis?
How frequently do you experience tension, muscle soreness, or other physical discomforts? 5 = often, 10 = very often
How would you rate your current level of stress?
How often have you felt anxious or overwhelmed in the past week?
How would you rate your sense of resilience or ability to handle challenges?
On average, how would you rate the quality of your sleep?
How rested do you feel upon waking up?
How often do you engage in activities that you find nurturing or fulfilling?
How confident do you feel in your ability to take care of your own well-being?
How connected do you feel to a supportive community or network?
How often do you feel lonely or isolated? [ 0= never, 5= often, 10 = very often]
How clear are you on your personal goals and what you hope to achieve?
How confident do you feel in your ability to achieve your personal goals?
How would you rate your sense of self-worth and value?
How optimistic do you feel about your future?

IX: Applicant Commitment & Acceptance of Terms and Conditions
By applying for the Heroic Hands Scholarship, I commit to the following:

• I will attend all scheduled sessions for the duration of the program.

• I will complete any follow-up surveys or questionnaires to help track the impact of services.

• I will provide honest feedback to improve the program for future participants.
X. Applicant's E-Signature
By signing the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
Signature

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Is there anything else you would like to add to this application before you submit it?
Heroic Hands Bodywork & Wellness LLC is committed to equal opportunity in wellness. We do not discriminate in any program or activity based on race, color, religion, gender, age, national origin, disability, marital status, or any other protected class.
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Scholarship Application Form

I. Personal Data

II. Veteran Status

III. Health Information

IV. Coaching Services

V. Income

VI: Motivation and Commitment

VII: Future Impact and Community Involvement

VII: Quality of Life Survey

IX: Applicant Commitment & Acceptance of Terms and Conditions

X. Applicant's E-Signature