GSP Request Form — Heart Warrior Ministries

Good Samaritan Project

CICU Enrollment Form

The Good Samaritan Project purchases and disperses food and Visa gift cards to families with a child in the ICU recovering from heart surgery.

We understand some heart centers are able to financially support these expenses for families, but not every one is able to do so. If you would like to enroll a family from your heart center in this program, please complete the form and someone will be in touch with you.

The below form is to be completed by a Case Worker on behalf of a family in need.

Name of the institution you work at?

Your Name

First Name

Last Name

Your Position/Title?

Email

Cell Phone

(###)

###

####

Preferred method of contact?

What day/time is best to contact you?

Name of the family you are referring? (First and Last Name)

Are they inpatient at your facility?

Yes

No

What type of financial assistance do they require?

Food, Parking, Other

For 501(c)(3) documentation purposes, provide a very brief description of why they are admitted for CHD related concerns and why they are applying for financial assistance. (please omit confidential information)

What is the address to your hospital? (needed to ship financial assistance to you) - Be as specific as possible to ensure shipment.