Patient Name *

First Name

Last Name

Diagnosis Date *

MM

DD

YYYY

Date of Birth *

MM

DD

YYYY

Ethnicity

American Indian or Alaska Native

Asian

Hispanic, Latino, or Spanish

Native Hawaiian or Pacific Islander

White

Black or African American

Language Spoken

English

Spanish

Creole

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

Insurance Company's Phone

(###)

###

####

Name of Policy Holder

First Name

Last Name

Hospital Main Phone #

(###)

###

####

Pediatrician's Phone Number *

(###)

###

####

Social Worker's Name

First Name

Last Name

Social Worker's Office Phone #

(###)

###

####

Social Worker's Cell Phone #

(###)

###

####

Do you have an open child welfare case?

Yes

No

Physician's Name

First Name

Last Name

Physician's Phone #

(###)

###

####

Mother/Other Name *

First Name

Last Name

Mother/Other Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother/Other Cell Phone # *

(###)

###

####

Mother/Other Home Phone #

(###)

###

####

Work Phone

(###)

###

####

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father/Other Name

First Name

Last Name

Father/Other Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father Other Cell Phone #

(###)

###

####

Father/Other Home Phone #

(###)

###

####

Work Phone #

(###)

###

####

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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.

Accept

I certify that to the best of my knowledge the information I have provided is complete and accurate. I understand that the information I have given is subject to verification by Chasin A Dream Foundation. 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. Information may be shared verbally or by computer data transfer, mail or hand delivery. I further understand that Chasin A Dream Foundation is a privately funded organization and the final determination of granting of financial assistance is based on the availability of funds and the governance of its Board of Directors. I also grant Chasin A Dream full photo/media privileges of my child. We/I give permission for my child/children to be photographed and videotaped during Chasin A Dream Foundation's activities. My child's image may appear in print or online promoting Chasin A Dream Foundation's activities. I understand that my child's first name may be used to identify my child. *

I agree.

Parent/Guardian *

First Name

Last Name

Parent/Guardian

First Name

Last Name

Date *

MM

DD

YYYY

Phone

(###)

###

####