Children’s Medical Rehabilitation Program Application

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Dear Applicant,

Thank you for your interest in the Children’s Medical Rehabilitation Program (CMRP).

The following is an application for the CMRP. Please read the application carefully and follow all directions. If you have any questions, please email us at ministries@isohimpact.org. After you have filled out the application, please submit the application through the email. Make sure you save a copy for your own files.

ISOH/IMPACT will endeavor to locate sources to assist you in providing medical treatment for your child. Upon approval, each applicant must be prepared to pay a non-refundable application fee of $25.00 USD as well as a roundtrip ticket to the United States of America.

Please be advised that all applications are reviewed by ISOH/IMPACT, medical institutions and health care professionals and must be approved by all.

Documents must be completed and returned by email and/or mailed to our offices before any final determination will be made.

Sincerely,
Linda A. Greene, RN Ph.D.
President/CEO
ISOH/IMPACT

Children’s Medical Rehabilitation Program Application – PDF

 

    Contact Information

  • Checklist

  • If application is not complete, the application will not be reviewed or accepted.
  • ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE STRICTLY CONFIDENTIAL AND WILL BECOME A PART OF YOUR MEDICAL RECORD

  • PERSONAL HEALTH HISTORY

  • Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, Hepatitis B and Tuberculosis.

  • MEDICATIONS & ALLERGIES

 

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