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*
MM slash DD slash YYYY

Nominator (if applicable)


Schedule B: Heartfelt Desire Details

Please be specific in your answers and include as much detail as possible.
2. Explain the history behind this Heartfelt Desire?

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.
- 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.