Family Sponsorship Application

Gavin’s Got Heart is very active in our local community and it is our goal to fulfill as many requests as possible. However, due to the overwhelming number of requests we receive from heart families, priority is given to families on Long Island and in the New York Metropolitan area. Please choose, from the options below, your region of residence:

If you are human, leave this field blank.

Region of Residence *

Parent/Guardian's Name *

First and Last

Address *

Street, City, State, ZIP

Phone Number *

Area code included

Email Address *

Child's Name *

First and Last

Child's Birthdate or Due Date *

Child's Diagnosis *

Are either of the parents employed? *

Annual family income:

Does the family have insurance coverage? What is the deductible? Are medical procedures/medications/surgeries/hospital stays covered?

Who resides in the household with the child? *

Current housing:

Physician Reference Name *

Physician's Address *

Street, City, State, ZIP

Physician's Phone Number *

Area code included

Physician's area of Medicine *

If granted, which expenses will the donation be applied towards? *

Please tell us about your child’s journey (surgeries, medications, length/frequency of hospital stays, etc.):

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