Gas Card Form - Enduring Hearts

ROAD TO RECOVERY GAS CARD PROGRAM

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 Date of Birth*
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
Hospital Social Worker's Email*
Primary Reason for Heart Transplant*
Transplant Status*
If Post Transplant, Date of Transplant

Date of Heart Transplant
If Pre Transplant, Date Listed for Transplant

Date when put on heart transplant list
Please choose a gas station from the dropdown menu:*
Gas Cards will be mailed by approximately 2-3 wks after submission deadline via a third party
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Comments
This field is for validation purposes and should be left unchanged.

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Save Lives as an
Organ Donor

Enduring Hearts Inc.
is a Registered 501(c)(3)
Charity EIN 46-2665745

info@enduringhearts.org
(240) EHEART-1
3600 Dallas Highway, Suite 230-350
Marietta, GA 30064

ROAD TO RECOVERY GAS CARD PROGRAM

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