Better Healthier Children Scholarship Application

Better Healthier Children Scholarship Application
Better Healthier Children is a non-profit 501c3 that abides by all HIPAA rules & regulations.

The goal of Better Healthier Children is to reduce brain & nervous system stress from chemical, emotional, and physical stressors during prenatal and early childhood development.
Child's Name:*

First NameLast Name
Child's Age*
Child's Date of Birth*

MonthDayYear
Date
Person Filling out this Form*

First NameLast Name
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Relationship to the Child:*
YesNo
Used alcoholUsed illicit drugsSmoked cigarettesWas fearful for her safetyWas homelessHad no healthy support systemWas diagnosed with health problemsWas induced into laborMeconium was presentRelinquished parental rights at birthDid not take vitaminsFather chose to be uninvolved in pregancy
Please explain health problems:
Cord wrapped around neck during birthWas removed from mother/fatherHad decreased vital signsC-section was performedSpent time in NICUNeeded assistance breathing/feedingNever given breastmilkWas in violent environmentCigarettes/alcohol abuse/ illicit drugs in householdBorn with addiction & experienced withdrawals
Failure to thrivePickingAsthmaPhysical Behavior issues: biting, hittingBowel IssuesJaundiceADHDAutismSensory sensitivityDelayed speechInsomniaFrequent Ear infectionsTorticollisNeeded a helmetSelf-Injury
Please list the # of ear infections your are aware of:
Please list all current and former medications:
AcupunctureDietary ChangesSupplementsOther
Please explain care taken and effects noticed:
Are there any current issues that would require immediate care?
YesNo
YesNo
YesNo
Child's Name:*

First NameLast Name
Guardian Name:*

First NameLast Name
Signature of parent/guardian:*
Should be Empty: