ETHAN VIDA ORGANIZATION
HOME
ABOUT US
The INVINCIBLE VICTIM
APPLICATION
VOLUNTEER WITH EVO
DONATIONS
ANNOUNCEMENTS
EVENTS
Songs and Video
CONTACT
ETHAN VIDA ORGANIZATION
APPLICATION FORM
PATIENT INFORMATION
*
Indicates required field
Patient's Name
*
First
Last
Date of Birth
*
(day/month/year)
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
*
yes
not at this time
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
*
Phone
Email
Text
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
[object Object]
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
*
yes
no
If Yes, OHIP Number
*
Other Medical Coverage
*
Account Number and Contact Details
Is This an Exceptional Case?
*
No
Yes
Not Sure
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
HOME
ABOUT US
The INVINCIBLE VICTIM
APPLICATION
VOLUNTEER WITH EVO
DONATIONS
ANNOUNCEMENTS
EVENTS
Songs and Video
CONTACT