APPLICATION FOR SERVICES I am requesting status as a patient of Grass Roots Wellness due to the following, select most appropriate option: (Low Income, First Responder, Teacher/Olympic Athlete) Name Email Phone SELECT ONE SELECT ONE *LOW INCOMEDISABLEDFIXED INCOMEOTHER (EXPLAIN BELOW) OTHER: FAMILY SIZE FIRST RESPONDER FIRST RESPONDER *FIRE FIGHTERACTIVE MILITARYVETERANOTHER (EXPLAIN BELOW) OTHER: BADGE # / ID # / PLEASE UPLOAD COPY OF BADGE OR ID FOR VERIFICATION TEACHER OR OLYMPIC ATHLETE (PLEASE UPLOAD PROOF OF EMPLOYMENT: PAYSTUB OR ID FOR VERIFICATION ONLY) TEACHER OR OLYMPIC ATHLETE (PLEASE UPLOAD PROOF OF EMPLOYMENT: PAYSTUB OR ID FOR VERIFICATION ONLY) *TEACHEROLYMPIC ATHLETE UPLOAD FILE File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png. Max. file size: 15 KB Submit
