First Responder Application - Rocky Mountain Hyperbaric Association for Brain Injuries

Applicant Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth*

Daytime Phone Number*

Email*

Select One:*

Currently employed as first responder
Previous first responder

Job title when you were injured:*

Employer when you were injured:*

Was this a job related brain injury?*

Yes
No

The following information is collected for our funders, who like to know the populations we are serving through our programs:

Gender:*

Female
Male

Ethnicity:

How did you hear about Rocky Mountain Hyperbaric Association for Brain Injuries?*

Website
Doctor Referral
Friend

*Please note, all information provided is for internal use only. No information provided is shared with any other entities or organizations.

The following information is required in order to process your application for approval.Please note that all materials, including, but not limited to, photos, news clippings and videos will not be returned.

Proof of employment:*

Drop files here or

Please provide documentation showing that you were employed by the employer mentioned above at the time of your injury.

Proof of work related injury:*

Drop files here or

Please provide documentation which verifies that you received your brain injury in the line of duty.

Please describe how you received your work related brain injury:*

Please describe your brain injury symptoms:*

What are your recovery goals?*

Financial Information

Annual household gross income:*

Annual household expenses:*

Honesty and Integrity

At Rocky Mountain Hyperbaric Association for Brain Injuries, 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 in order to be considered for a grant from the Rocky Mountain Hyperbaric Association for Brain Injuries.

Release Form

Along with financial assistance programs to help pay for hyperbaric oxygen therapy treatments, the Rocky Mountain Hyperbaric Association for Brain Injuries 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 in order to share results and the need for the association. Personal health information from the medical director of Rocky Mountain 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 signing this document, I acknowledge the following:

As a participant in the Rocky Mountain Hyperbaric Association for Brain Injuries, I authorize permission for the Rocky Mountain Hyperbaric Association for Brain Injuries to collect information from the medical director of Rocky Mountain 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.

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Applicant's Signature*

Date

This form collects personal information so we can contact you to discuss your request. Take a look at our privacy policy for the full story.

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I understand by submitting this form I agree to the privacy policy.

I understand that Rocky Mountain Hyperbaric Association will use this information to contact me regarding my inquiry.