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Apply for Help / Application Form / US Application
US Application
If you are interested in applying for medical help from Fresh Start Surgical Gifts and you live in the United States, please fill out the application form below as completely as possible. If you are unsure if your condition falls under Fresh Start Surgical Gifts' scope, please visit the Who Can Apply page for information on what types of condition Fresh Start Surgical Gifts' treats.

If you have any questions about the application process, please contact Lupita Morales, Patient Services Coordinator, at 760-448-2025 or lupita@freshstart.org.
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Applicant Information
Applicant's First Name:*
Applicant's Last Name:*
Applicant's Middle Name:
Street Address:*
City:*
State:*
Zip Code:*
County of Residence:
Daytime Telephone:*
Evening Telephone:*
Sex:*
Applicant's Email (Please input only ONE valid e-mail address):*
Date of Birth:
Month:*
Day:*
Year:*
If you are 17 years or older, you are required to upload a short essay which answers the following questions:
-Who are you and what are you personal interests & work experience?
-What is your educational background?
-Why are you applying to Fresh Start?
-How will this gift change your life?
-What will you give back in return for the gift from Fresh Start?
Please do not exceed 2 pages
Citizenship of prospective patient:*
Language patient/patient's parents speak:*
How did you learn about Fresh Start Surgical Gifts:*
Parent/Guardian Information
Parent/Guardian First Name:*
Parent/Guardian Last Name:*
Parent/Guardian Middle Name:
Street Address of Parent/Guardian:*
City:*
State:*
Zip Code:*
Parent/Guardian Daytime Telephone:
Parent/Guardian Evening Telephone:
Parent/Guardian's Email (Please input only ONE valid e-mail address):*
Parent/Guardian Sex:*
Description of Condition
The following lists the surgical procedures performed at Fresh Start. Please select the type of surgery or treatment needed:*
If you selected "Other" above, please describe:
Is the problem:*
Any other health problems:*
Any Allergies:*
List any medications currently taking:*
Name of Physician:*
Physician's Telephone:
Has the prospective patient received any treatment for the problem?*
If you answered yes to the previous question, describe all previous surgeries and treatments with dates:
Please attach copies of all medical records related to treatments you have received for your problem:
*If you do not have copies of your medical records, after submitting your application please contact the Patient Services Coordinator, Lupita Morales, at (760) 448-2025 or lupita@freshstart.org, to fill out a Disclosure of Medical Records Release Form.
Please attach current front and side-view photographs of problem area:
Does the patient have medical insurance coverage?*
If you answered yes to the previous question, please specify the type of medical insurance coverage:
If you have medical insurance coverage, please attach a copy of both sides of your insurance identification card:
Have you been denied insurance coverage for your problem?*
If you answered yes to the previous question, please attach a copy of the denial letter for your insurance provider:
Household Information
Please list names of patient and family members. Include the income source/type of employment for each family member, their age, their relation to the prospective patient, their gross yearly income, and if he or she is a dependent. Include SSI, SSD, IHSS, Child Support, Pension, Retirement, and other types of regular assistance:*
Total Household Gross Annual Income:*
If a US citizen, please attach a copy of the most current filed IRS tax return. Provide only the 1040 forms. Please omit your social security number.
Do you:*
What is your monthly rent or monthly mortgage payment:*
What is the amount of your total assets (what you own):*
What is the amount of your total liabilities (what you owe):*
Make sure you have included everything listed below (if applicable) before submitting your application:*


By checking the box below, I declare under the penalty of perjury that the foregoing is a true and accurate statement as to the availability of any insurance or state funded reimbursements for the surgery requested of Fresh Start Surgical Gifts, Inc.*
Type Full Name:*