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
This form to be completed mailed or sent electronically by the parent/guardian of the applicant.
The Family Section
(Complete if Child is Ward of the State, without living parents)
The Medical Section
“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.”
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- email@example.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.