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Hero's With Handicaps Application

Posted Jul 27 2008 6:12pm
Hero's With Handicaps, Inc.

Service Request Application



1. Child's Name______________________________________________________________________



Child's Age ______________________________________________________________________



2. Address __________________________________________________________________________



________________________________________________________________________________

City State Zip



3. Phone #'s_________________________________________________________________________

Home Work Cell



4. Email___________________________________________________________________________



5. Child's Disability(ies)___________________________________________________________



________________________________________________________________________________



6. Parent's Names____________________________________________________________________



7. Military Service (circle one) Active Duty Retired



________________________________________________________________________________

Branch of Service Rank



8. What service are you requesting financial assitance for? ______________________



________________________________________________________________________________



________________________________________________________________________________



________________________________________________________________________________



9. Briefly state why you are requesting financial assistance and how your child will benefit.



________________________________________________________________________________



________________________________________________________________________________



________________________________________________________________________________



________________________________________________________________________________



________________________________________________________________________________



10. Have you exhausted all public assistance (insurance, public school, and state resources)?



________________________________________________________________________________



________________________________________________________________________________



________________________________________________________________________________



________________________________________________________________________________



________________________________________________________________________________



Please mail this application along with:

1. Letter from physician stating your child's diagnosis/disability (ies)

2. Copy of PCS orders or DD-214



Mail to Heroes With Handicaps, Inc.

22519 Country Cove Lane

Katy, TX 77494
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