Qualify for Donation/Sponsorship Questionnaire for Veterans & First Responders Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Birth* Day Time Phone Number*Email* Name of Legal Guardian (if under 18):Select One*Active DutyVeteranDid You Serve In*OEFOIFBothThe following information is collected for our funders, who like to know the percentage of populations serviced through our programs:GenderMaleFemaleEthnicityHispanicBlackAsianIndianWhiteHow did you hear about the Rocky Mountain Hyperbaric Association for Brain Injuies?WebsiteDoctor ReferralFriend*Please note, all information provided is for internal use only. No information provided is shared with other entities or organizations.Financial InformationAnnual Gross Household IncomeAnnual Household Living ExpensesPlease describe your brain injury. What are your symptoms?*What are your recovery goals?*Honesty and Integrity At Nirvana Healing Foundation, we feel that it is of critical importance that honesty and integrity be adhered to in all aspects of our business. We firmly believe in personal accountability for all our actions and expect honesty and integrity from all our clients. We require that you read and sign our Statement of Understanding to be considered for a grant from Nirvana Healing Foundation. Statement of Understanding By submitting this questionnaire, I swear, to the best of my knowledge, that the information I have provided is the truth. I understand that if I am selected to receive financial assistance from Nirvana Healing Foundation, and it is found that I have not fully disclosed all required information, or I have lied about any information, it will be my responsibility to fully refund the money which I have been wrongly awarded due to my fraudulent actions. Failure to pay back any monies owed could result in legal action. I also understand that I must complete this application in its entirety. Failure to provide all required information and items associated with this application will result in immediate rejection of my application. I further understand that it is not the responsibility of Nirvana Healing Foundation to request any missing items from my application. I understand that information of all clients is confidential, and I will not divulge any personal information about other clients of Nirvana Healing Foundation or any personal information regarding any patients of the Rocky Mountain Hyperbaric Institute. Release Form Along with financial assistance programs to help pay for hyperbaric oxygen therapy treatments, Nirvana Healing Foundation does outreach, fundraising, and marketing (i.e. website, seminars, brochures, etc.) work to keep the association information available to the community. Documentation of participant involvement and usage of material (photo, bio, testimonial, etc.) is important to share results and the need for the association. Personal health information from the medical director of Nirvana Hyperbaric Institute and your medical care physician(s) will benefit our work and increase our community support. Your release to obtain and share personal and health documentation is needed for this purpose. By submitting this questionnaire, I Acknowledge the Following As a participant in Nirvana Healing Foundation’s treatment program, I authorize permission for Nirvana Healing Foundation to collect information from the medical director of Nirvana Hyperbaric Institute and/or my medical care physician(s) regarding my health status and/or improvements since receiving hyperbaric oxygen therapy treatments and usage of my photo, bio, testimonial toward actions mentioned above.Date* CAPTCHA
