Pain Awareness Month 2019 | Proclamation application form
Please fill out all questions within the application form. We will respond to your application within 2-3 business days with next steps.

If you have any questions or need help obtaining specific information relating to this initiative, please email

Email address *
First name *
Your answer
Last name *
Your answer
Please provide your town/city: *
Your answer
Please provide your state: *
Your answer
Are you a volunteer with U.S. Pain Foundation? *
Have you submitted a proclamation request in the past? *
If selected as the state lead, are you willing and able to provide the U.S. Pain team with status updates relating to the proclamation request? *
Photographs are used by U.S. Pain Foundation to celebrate the efforts of volunteers by sharing the image on social media. If chosen to represent your state by submitting the Pain Awareness Month proclamation request, do you agree to take a photograph of the approved proclamation? (Examples can be found at right.) *
If selected as the state lead, do you agree to mail the hard copy proclamation to the U.S. Pain Foundation main office? *
If a fellow pain warrior has already been selected to represent your state, are you willing and able to submit a proclamation request to your local government (Mayor/First Selectman, etc.)? *
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This form was created inside of U.S. Pain Foundation inc.