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?*
Primary 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*
This 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*
Gas 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*
Social Worker's Name*
In order for us to process your request, please be sure to choose your child's correct social worker from the dropdown menu
Primary Reason for Heart Transplant*
Transplant Status*
If post transplant, date of transplant*
MM slash DD slash YYYY
CAPTCHA
Visa 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.
Phone
This field is for validation purposes and should be left unchanged.

ROAD TO RECOVERY GAS CARD PROGRAM

Visa 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.

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