APPLICATION

ETHAN VIDA ORGANIZATION
APPLICATION FORM

PATIENT INFORMATION

* Indicates required field

Patient's Name *

First

Last

Date of Birth *

Age at Time of Application *

Gender *

Recent Photo of Your Child *

Max file size: 20MB

Ethan Vida Organization asks your permission to use photographs that may include your child’s image in our promotional materials (for use in campaigns, fundraising, general type of promotion, research funding applications, etc.).

Photo Consent *

A downloadable consent form and application are available at the bottom of this form should you prefer to fill it out and mail/email

CONTACT INFORMATION

Preferred Method of Contact *

Mother's Full Name *

First

Last

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Email Address *

Father's Full Name *

First

Last

Father's Mailing Address (if different) *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Email Address *

Foster Care/Legal Guardian's Name (If Applicable) *

First

Last

Foster Care/Legal Guardian's Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Email Address *

MEDICAL INFORMATION

Diagnosis: *

Medical History (point form please) *

Present Medical Condition (point form please) *

Medical Challenges (point form please) *

AVAILABLE RESOURCES

Source(s) of Income *

OHIP? Pick one *

If Yes, OHIP Number *

Other Medical Coverage *

Is This an Exceptional Case? *

Submit

evo_application_form_2023.docx
File Size:	16 kb
File Type:	docx

Download File

evo_consent_for_photography_of_child_2023.docx
File Size:	94 kb
File Type:	docx

Download File

ETHAN VIDA ORGANIZATIONAPPLICATION FORM

ETHAN VIDA ORGANIZATION
APPLICATION FORM