Health Missions | Healthcare. Education. Research.

To apply for an upcomming Health Missions Trip please complete the form below and submit it to Health Missions. You may either complete the form online, or you may download the .pdf version of the form, complete it by hand and mail it to us.

Chiro Kids Healthcare Fund Application

	Child Information
	Child's Name:
	Age:	Gender: Male Female
	Address:
	City:	State: Zip:
	Parent / Guardian Information
	Name:
	Age:	Gender: Male Female
	Address:
	City:	State: Zip:
	Phone Number:
	Email:
	Background Information
	Current condition Child is suffering from
	Detailed Explanation of Medical History (include medications, diagnostic tests, surgeries, etc.) :
	Why should you or your child be picked to receive the Chiro Kid’s Scholarship Fund?
	By checking this box, I understand that the natural healthcare services I will potentially receive are not designed to treat disease. Regardless of the name of the disease they will not treat it. The only goal is to assist my body with its inborn potential to heal itself. Although Health Missions, LLC will need to know the conditions that I am suffering from they will not treat the condition.
	By checking this box, I understand that Health Missions, LLC does not advise you to stop the current treatment you are receiving. They will focus on the integration of natural healthcare services to assist in your overall recovery.
	Please enter today's date to help confirm your application and understanding of the terms of the scholarship:

You may also download a hard copy application: ChiroKids Scholarship Application