Gas Card Form ROAD TO RECOVERY GAS CARD PROGRAM Starting in 2023 Visa gas cards will be issued for the Road to Recovery program. They can only be redeemed at gas stations (ex. Shell, BP). Purchase must be made inside of station NOT at pump. Cards will be mailed 2-3 wks AFTER the application deadline by a third party vendor. Cards are valid for 6 months once received.Have you or another caregiver applied for the Enduring Hearts Gas Card Program before?*.YesNoOther family member appliedPrimary Caregiver's First Name* Primary Caregiver's Last Name* Primary Caregiver's Street Address* City* State* Zip Code* Has your address changed since the last time you applied?* Yes No This is my first time applying Cell Phone* Primary Caregiver's Email* Additional Caregiver's First Name Additional Caregiver's Last Name Additional Caregiver's Email Child's First Name* Child's Last Name* Child's DOB* MM slash DD slash YYYY Child's Race*.WhiteBlack or African AmericanHispanicAsianNative American or Alaska NativeTwo or More RacesThis information is used collectively to help identify the population in which we serve for reporting to other non profit agencies and government. Total Annual Family Income*.Less than $25,000$25,000 to $34,999$35,000 to $49,999$50,000 to $74,999$75,000 to $99,999$100,000 to $149,999$150,000 to $199,999$200,000 or moreGas cards participation is not based upon need. Enduring Hearts uses the collective information for reporting to government agencies, and other non profits the population demographics in which we serve. Your information is private. Transplant Center/ Hospital*.Ann & Robert H. Lurie Children's Hospital of ChicagoArkansas Children's HospitalAtrium Health Levine Children's (Charlotte)Boston Children's HospitalC.S. Mott Children's Hospital (Michigan)Children's Hospital of AtlantaChildren's Hospital ColoradoChildren's Hospital of PhiladelphiaChildren's Hospital of PittsburghChildren's Hospital of WisconsinChildren's Hospitals and Clinics of MinnesotaChildren's Medical Center DallasChildren's Mercy KansasChildren's National Medical CenterChildren's of AlabamaCincinnati Children's Hospital Medical CenterChildren's Hospital of MichiganCleveland ClinicJohns Hopkins All Children's Hospital (FL)Johns Hopkins Hospital (Baltimore)LeBonheur Children's HospitalLucile Packard Children's Hospital StanfordMedical University of South CarolinaMonroe Carell Jr. Children's Hospital at VanderbiltMorgan Stanley Children's Hospital of New York PresbyterianNYU LangonePhoenix Children's HospitalPrimary Children's Hospital (Salt Lake City)Seattle Children's HospitalSt. Louis Children's HospitalTexas Children's HospitalUCSF BenioffUF Health Shands Children's HospitalUniversity of Virginia Children's HospitalSocial Worker's Name*.Akina TakahashiAllison McGillAmelia WetzelAnna BaileyBecky SulkinBetsy LongCallie DavilaCarla JacksonCassidy BegashawCassie StewartChanta BrownCharisse RhoneChelsea WeinsteinChris KozelClaire PrinceColleen EtouDia Bright-JohnsonDawn WarfieldEmily HolmanErin OrmistonErin VillaniHannah OwensJade McCrayJamie-Leigh GansJen BaschJonathan RabatinKaitlyn SchenkelKathy DaleyKelley MabeyKevin JacobsonKristina MatkinsLisa SaldimandoMaricel FlorescaMegan MillerMeghan StuartMelanie EverittMichelle RhodesMolly DuganNatalie LeonNatasha DealRachel KleinbartRobin KostroskiRobin StoneSahar ShalashSamantha AlfordSamantha FloydSamantha FuellerSerena WhiteShari ScheferSharee RogersSharon BeckwithStaci AlvarezStefanie CurrySusan StrianoVer'Tanya JackVictoria ArmbrustIn order for us to process your request, please be sure to choose your child's correct social worker from the dropdown menuPrimary Reason for Heart Transplant*.Congenital Heart Disease - Single Ventricle HeartCongenital Heart Disease - Two Ventricle HeartDilated CardiomyopathyRestrictive CardiomyopathyHypertrophic CardiomyopathyPost-Chemotherapy CardiomyopathyRe-TransplantationOtherTransplant Status*.Post-Heart TransplantPre-Heart TransplantIf post transplant, date of transplant* MM slash DD slash YYYY CAPTCHAVisa gas cards can only be redeemed at gas stations (ex. Shell, BP). Purchase must be made inside of station NOT at pump. Cards will be mailed 2-3 wks AFTER end of cycle by a third party vendor.PhoneThis field is for validation purposes and should be left unchanged.