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:
Do you have medical rights to this child?
Biological Mother's Prenatal Health History (check all that apply)
Please explain health problems:
Child's Neonatal Health History (check all that apply)
Has the Child Been Diagnosed with, or Have You Noticed (check all that apply)
Please list the # of ear infections your are aware of:
Please list all current and former medications:
Other interventions currently/formerly attempted outside traditional medicine

Other
Please explain care taken and effects noticed:
Are there any current issues that would require immediate care?
I have the ability to get this child to appointments multiple times a week:
If I notice substantial benefit from chiropractic care, I am willing to participate in spreading the word. This means I will allow Better Healthier Children to use testimonials, images, and the child's story to help educate others.
I (guardian / foster parent) am currently experiencing financial hardship and could not otherwise afford chiropractic care.
Child's Name:

First NameLast Name
Guardian Name:

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