Date Requested *

MM

DD

YYYY

Patient Name *

First Name

Last Name

Child's Birthdate

MM

DD

YYYY

Date of Diagnosis *

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

Currently Hospitalized? *

Yes

No

Pediatrician's Phone Number

(###)

###

####

Any Physical Handicaps?

Yes

No

Parent/Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Interested in our Holiday Toy Drive?

Yes

No

Authorization to Release Medical Information

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 I withdraw my permission, which can be done at any time.

I accept

Media Release Form

I give permission 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. This permission form will be kept on file in the Chasin A Dream Foundation's office. If I would like to withdraw my permission, I may do so at anytime.

I accept

(We/I) hereby request to participate in Chasin A Dream Foundation's programs which include, but are not limited to: Hospital Backpack Program, financial assistance, Pediatric Pantry, holiday toy/gift card assistance. I also grant Chasin A Dream full photo/media privileges of my child to be used for charitable purposes. I understand that my child's first name may be used to identify my child. (We/I) understand that no applicant shall be unlawfully denied services because of gender, race, color, creed, national origin, height or weight. It is the policy of Chasin A Dream Foundation to comply with all federal and state laws including laws that define and prohibit discrimination on the basis of age or handicap. (We/I) hereby release Chasin A Dream Foundation from any and all liability that may arise from my/our participation in Chasin A Dream Foundation's programs. I further agree that this release also covers and includes all unknown, unforeseen, unanticipated and unsuspected injuries, damages, losses and liabilities and their consequences, as well as those now disclosed and known by me/us to exist. Any provisions of any laws, statutes or regulations of any kinds that provide in substance that pleases shall not extend to claims, demands, injuries or damages, losses or liabilities, which are unknown to unsuspected to exist by the persons signing this release are herby waived. (We/I) have read and understand the above. *

I Agree