Kids Hearts Need You!

Gift of Life Of Rotary International District 7490

-Please print out the application below

-Fill out as completely as possible

-Return to the address below along with all necessary medical data

 

INFORMATION SHEET

 

This form to be completed mailed or sent electronically by the parent/guardian of the applicant. 

 

 

The Family Section

Country of Origin

 

Child’s Full Name

 

Nickname

 

Gender

 

Age

 

Date of Birth

 

Height

 

Weight

 

Religion

 

 

Father’s Name/ Age/Occupation

 

 

Mother’s Name/age/Occupation

 

Is Mother pregnant?

 

Complete Mailing Address

 

E-mail Address/s

 

Telephone No/s.

 

FAX No.

 

Mobile Phone No/s.

 

Family Annual Income (U.S. $)

 

 

Name of Guardian

 

Relationship to the Patient

 

Complete Mailing Address

 

 

E-mail Address/s

 

Telephone No/s.

 

FAX No.

 

 

 

 

Orphan Section-

(Complete if Child is Ward of the State, without living parents)

 

Orphanage/Foster Home child is located at.

 

Director-

 

Contact info-

 

Is child eligible for adoption?

If Yes, Adoption agency holding case-

 

 

 

 

The Medical Section

Name of Referring Physician

 

Address

 

Phone/FAX/Mobile Phone Nos.

 

Diagnosis of Patient

 

 

Authorization

 

I hereby certify that the facts contained in this form are true and complete to the best of my knowledge and understand that, if accepted in the program, falsified statements on this form shall be grounds for cancellation of this application. I also authorize investigation of all statements contained herein.”

 

Date: 

 

 Signature over printed name:

 

 

Instructions:

ALL sections of this form must be completed if applicable. After completing this form, please print, sign and send to Gift of Life Foundation together with the accompanying required documentation.

                      Rev. Andrew Topp

                              Rotary International District 7490

                              Gift of Life Foundation

                              107 Spruce Street

       Midland Park, NJ 07432   USA

e-mail- giftoflife7490@aol.com, Phone-(011) 201-410-0155

 

 

 

 

Medical Record Requirements

 Gift of Life Foundation, Rotary District 7490

 

 

1- Information Form including Name, birth date, Parents’ names and current address, any contact information (e-mail address, phone number)

2-   General Medical History (required) Including Oxygen saturation levels

3-   Chest X-Ray (required)

4-   EKG (Required)

5-   ECHO cardiogram-report and video tape (required)

ECHO cardiogram-report and video tape (if at all possible) on VHS tape or CD--please send the full session, not just short clips

6-   Letter from sending doctor certifying surgery is needed in U.S. as well as an estimation of the critical nature of the case, and an opinion of the timeline surgery is needed in. (required)

7-   Letter from sending doctor that the child is well enough to fly to the USA

8-   At least one Recent clear photograph of the child (required)

9-   Family Social History (if possible)

 

Please also include: Child’s name, date of birth, Country of origin, Complete address, Parent/Guardian’s name, sending doctor/hospital’s name and address, U.S. Contact person name and address and sending contact person’s name and address.

Any E-mail Addresses for sending doctors, parents, or contact person would be helpful if available.

 

 

All children’s applications are considered as carefully as possible, decisions are based on the likelyhood of a positive outcome within a reasonable timeframe.