If you have received financial assistance from Help-A-Heart, we would love for you to fill out this form. This is for our records only and will be kept confidential. Please email [email protected] if you would like to be connected to our private facebook page or receive our monthly newsletters.  Thank you!

    Parent Name (required)

    Heart Child Name (required)

    Hospital Name (required)

    Admission Date (required)

    Gift Card Amount (required)

    Date Received (required)

    Email (required)

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