Heartfelt Desire Application

"*" indicates required fields

Before completing this application, please reference the end of the form to ensure the Heartfelt Desire
meets our Guidelines and Qualifications. Heartfelt Desires that do not meet our Guidelines and will not be considered for fulfillment. If you are nominating a CHD patient for a Heartfelt Desire, please remember that all questions refer to the individual being nominated. Please be as thorougn as possible to ensure your application is considered.

Section A: Contact Information

Patient Name*

First Last

Phone Number*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Birthday*

Nominator (if applicable)

Nominator Name

Nominator Phone

Address

Street Address Address Line 2 City State ZIP Code

Relationship to Patient

Schedule B: Heartfelt Desire Details

Please be specific in your answers and include as much detail as possible.

1. What is your Heartfelt Desire?

2. Explain the history behind this Heartfelt Desire?

2a) What makes this Heartfelt Desire meaningful to you? (300 character minimum)

2b) What prompted this Heartfelt Desire? (100 character minimum)

2c) When did you know you wanted this Heartfelt Desire? (100 character minimum)

3) Describe any benefits (emotional, physical, spiritual, social or intellectual) you think you will experience as a result of having this Heartfelt Desire granted: (100 character minimum)

4) How would granting this Heartfelt Desire inspire others and help Heartfelt Dreams Foundation in its goal to provide hope and happiness to CHD patients? This Heartfelt Desire and/or my story will inspire others because... (100 character minimum)

5) Why are you unable to fulfill this Heartfelt Desire on your own? (100 character minimum)

Schedule C: Personal History

Before we move forward with a Heartfelt Desire, we would like to try and get to know you. Please take the time to tell us a little about yourself. Nominators: Please remember that all questions refer to the individual being nominated for a wish.

1. What is your congenital heart defect diagnosis? Who is your cardiologist?

2. What treatment have you had for your CHD condition? When was your first procedure? (100 character minimum)

3. Do you have any upcoming procedures? (100 character minimum)

- When? At what hospital?
- Are you connected with a hospital social worker?
Include names, addresses, and contact information

Guidelines and Qualifications:

Confirmed congenital heart defect diagnosis
Minimum age of 3 years
Reside in the United States of America
Unable to fulfill the Heartfelt Desire on your own
Capable of experiencing the Heartfelt Desire
Able to obtain approval from a cardiologist, if necessary

What Will Not be Granted or Considered:

Financial Assistance (cash payment of bills, rent, taxes, etc.)
Housing Assistance (home repair/modification, assistance moving, locating housing, etc.)
Home Furnishings
Technology (computers, phones, cell phones, tv's)
Medical care or services
Legal Services
Vehicle (purchase, repair, modification)
Potentially harmful or dangerous Heartfelt Desire

Disclaimer: Unfortunately, Heartfelt Dreams Foundation is unable to grant every Heartfelt Desire we receive. The decision to grant a Heartfelt Desire is at the sole discretion of Heartfelt Dreams Foundation, and a Heartfelt Desire may be denied for any reason.

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