Empowerment Fund

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Please describe your goals with the Empowerment Fund and what service(s) you would like to utilize with the funds.

Please write a one-page response (or two minute video) addressing the following:

What do you want to achieve with this scholarship?
→ Describe your personal health or wellness goal.

What is your plan of action for utilizing the funds?
→ List the specific services and business(es) you plan to use as well as the estimated cost.

How will this scholarship impact you?
→ Share how this opportunity will support or improve your well-being.

Please confirm your commitment and understanding of program requirements.

First Name *

Last Name *

Birthday *

Gender *

What is your affiliation?

Race (select all that apply)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Some Other Race

Prefer not to say

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Email *

Phone 1 *

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

How did you hear about us? *

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Please attach a response answering the above questions outlining your plan and objectives with the Empowerment Fund.

1 page max

OR attach a video response answering the above questions outlining your plan and objectives with the Empowerment Fund.

max video length 2 minutes

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Can you commit to communicating periodically with a Health4Heroes team member during your scholarship period? *

Yes

Are you willing to provide required testimonials about your experience for program impact reporting and donor communications? *

Yes

Do you currently have access to health and wellness resources through other means? *

Yes - please explain below

If yes, please explain

Scholarship funds are not to exceed $500, in the event of the program costs being more, will you be able to cover the excess amount?

Yes

Data Privacy & Consent

Yes, I would like to receive text messages from Health4Heroes.

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Empowerment Fund