Home | Our Services | Our Mission | Donate | Contact Us | Membership | Facts | Photos | Websites

Become a Levine Cardiac Kids Member

Would you and your family like to become members of Levine Cardiac Kids? Please fill out the form below, we do not share this information. Membership in our group is free and open to the CHD child, parent(s)/caregiver(s) and the child’s family, as well as those with an interest or background in diagnosing, treating and/or supporting patients with CHDs. We welcome all CHD patients, parents, families; regardless of where any treatment has been given in the past, or will be given in the future.

Parent's First Name:
Last Name:
Street Address:
City:
State:
Zip:
Phone # (Home):
Phone# (Cell):
Email Address:
Other Email Address:
Name of Child with CHD:
Diagnosed CHD:
Age Diagnosed:
Birth Date of Child:
1 Sibling Name:
1 Sibling Birth Date:
2 Sibling Name:
2 Sibling Birth Date:
3 Sibling Name:
3 Sibling Birth Date:
4 Sibling Name:
4 Sibling Birth Date:
Pediatrician/Group:
Cardiologist/Group:
Surgeon/Hospital:
Brief description of treatment to date:
Additional surgeries needed/scheduled:
Other surgeries/Diagnosis:
Language Spoken:
Your child's website, if they have one?
How did you hear about us?

Home | Our Services | Our Mission | Donate | Contact Us | Membership | Facts | Photos | Websites