Date requested
*
MM
DD
YYYY
Patient Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Gender at Birth
Male
Female
Diagnosis
*
Date of Diagnosis
*
MM
DD
YYYY
Ethnicity
Language Spoken
If referred, please tell us who
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
(###)
###
####
Parent's Name #1
*
First Name
Last Name
Parent's Name #2 (if applicable)
First Name
Last Name
Do you have health insurance?
*
Yes
No
Insured's Name
Is the Patient covered by Private Health Insurance?
*
Yes
No
Name of Insurance Company
Insurance Company's Phone
(###)
###
####
Name of Policy Holder
First Name
Last Name
Relation to Patient
Parent
Other
Is there Secondary Insurance?
Yes
No
Is the Insurance Company State Funded?
Yes
No
Have you completed the Medicaid Application?
Yes
No
Does your insurance provide transportation?
Yes
No
Referring Hospital
Hospital Main Phone #
(###)
###
####
Name of Pediatrician
Pediatrician's Phone Number
*
(###)
###
####
Social Worker's Name
Social Worker's Office Phone #
(###)
###
####
Social Worker's Cell Phone #
(###)
###
####
Social Worker's Email
Do you give permission for social worker or case manager to release your information to Chasin A Dream Foundation for review for assistance?
Yes
No
Physician's Name
First Name
Last Name
Physician's Phone #
(###)
###
####
Is your child enrolled in a PPEC?
Yes
No
If your child is enrolled in a PPEC, please provide the address/phone number
Do you have an open child welfare case?
Do you own or rent your home?
Rent
Own
Medicaid
*
Yes
No
Foodstamps
*
Yes
No
Child Support
Yes
No
SSI
*
Yes
No
Pension
Yes
No
Unemployment benefits
Yes
No
Have you received financial assistance from other organizations? Please list them and $ amount
What are your needs currently for assistance?
*
How does the current medical situation impact the care giver(s) ability to work?
Describe your support network: (Family, friends, work, community etc.)
Will your support of network be willing to help with fundraising efforts if needed?
Do you have a GoFundMe?
Yes
No
If yes, what is the name of the GoFundMe account and amount?
Relationship to Child
*
Mother
Other
Marital Status
*
Single
Married
Divorced
Separated
Mother/Other Name
*
First Name
Last Name
Mother/Other Social Security #
*
Mother/Other Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mother/Other Cell Phone #
*
(###)
###
####
Mother/Other Home Phone #
(###)
###
####
Email
Mother/Other Employer
*
Work Phone
(###)
###
####
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
(###)
###
####
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Position
Maritial Status
Single
Married
Divorced
Separated
Child lives with
Parent's Living Arrangement
Father/Other Name
First Name
Last Name
Father/Other Social Security #
Father/Other Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Father Other Cell Phone #
(###)
###
####
Father/Other Home Phone #
(###)
###
####
Email
Father/Other Employer
Work Phone #
(###)
###
####
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Position
Chasin A Dream Foundation may need to reach out to other organizations in an effort to support your child and family. Acceptance below allows us to speak or write in text or email to organizations and health care providers on your behalf to provide the most comprehensive support we can. By accepting below you voluntarily authorize disclosure of all your health information including sensitive conditions. This authorization will remain in effect until you withdraw the permission, which can be done at any time.I also understand that I am responsible to inform Chasin A Dream Foundation of any change in status. I grant permission to Chasin A Dream Foundation to use/release my information submitted, and disclose and request on my behalf to other agencies, providers, doctors, and medical facilities for the purpose of case management, assistance and advocacy and understand that I can revoke this permission at any time in writing. If Chasin A Dream Foundation refers you to any organizations the foundation is not liable for any injuries or damages.
Application Agreement: I hereby apply for assistance to meet medical and/or non-medical expenses related to my child's medical care not covered by my public/private insurance or any other agency and that I cannot otherwise pay without hardship. The type and amount of assistance provided will be determined by Chasin A Dream Foundation. I vouch for the truth and accuracy of all information given in this application. I authorize disclosure of information relevant to my child's medical condition to Chasin A Dream Foundation. I also authorize disclosure to Chasin A Dream Foundation of any information relevant to my application as well as any information from insurance or other pertinent agencies. I have been informed that any false submitted documentation or information will automatically disqualify this application and eligibility for any further assistance from this organization. I understand that Chasin A Dream Foundation Board of Directors determines the amount they will assist for each family by case-by-case basis.
*
Parent/Guardian Agreement: I hereby consent to Chasin A Dream Foundation to to use my child's story to be told. I release them from any expectation of confidentiality for the udnersigned minor children and myself and attest that I am the parent or legal guardian of the child listed.
*
Photographic and Video Release and intellectual Property Rights: I grant full permission and rights to use, without compensation, photographic images and videos of me and my children and quotations made by me and my children relating to our service in materials, advertisements, and other promotions for Chasin A Dream Foundation. I understand that this is the policy of Chasin A Dream Foundation to use only first-names, pseudonyms, or de-identified images, videos, or quotations in it's materials to help protect my privacy and the privacy of my child(ren).
*
Parent/Guardian
*
First Name
Last Name
Parent/Guardian
First Name
Last Name
Date
*
MM
DD
YYYY
Phone
(###)
###
####
