Patient Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Diagnosis Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent #1 Name *

First Name

Last Name

Parent #2 Name

First Name

Last Name

Phone *

(###)

###

####

Alternative Phone *

(###)

###

####

Do you have health insurance *

Yes

No

Have you applied for any of the following? *

Medicaid

Food Stamps

SSI

None of these

Date approved for Medicaid (if applicable)

MM

DD

YYYY

Date approved for Food Stamps (if applicable)

MM

DD

YYYY

Date approved for SSI (if applicable)

MM

DD

YYYY

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. 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. *

I agree

Your Name *

First Name

Last Name

Date *

MM

DD

YYYY