Non-Profit Eligibility Form

Non-Profit Eligibility Form

This short form makes it simple to determine eligibility for nonprofit care (medical, chiropractic, acupuncture, etc). Form Preview
Thrivability Eligibility
Non-Profit Eligibility Form
  • 1

    Your Company Name is a 501(c)(3) charitable organization. We believe that everyone deserves access to this wonderful service and that finances should never be a barrier to experiencing its many powerful benefits. We are proud to serve underserved populations including those with low income, severe medical disabilities, and our first responders (fire heroes, police officers, active military, and veterans).

    Please take a few moments to complete this short form to see if you are eligible for our program.

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  • 2
    First Name
    Last Name
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  • 3
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  • 4
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  • 5
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  • 6
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  • 7
    Please present your badge or ID for verification.
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  • 8
    *Annual Household Income is the combined earnings for one year of all adults sharing a residence. 
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  • 9
    Include all adults and children living at your place of residence.
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  • 10
    Please sign and click submit.
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