Local Fuel Assistance Grant Application

Local Fuel Assistance Grant Application

The following application is ONLY for families whose babies are:

being admitted to Children's Memorial Hermann Hospital (CMHH) in Houston, Texas
has a verified CDH (Congenital Diaphragmatic Hernia) diagnosis
will be living at home while their baby is admitted; NOT relocating closer to CMHH

If accepted, your family will receive $100 in a gas gift card for a maximum of 4 months (or until your baby is no longer admitted in the hospital)

First & Last Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

How many miles separate your home from Children's Memorial Hermann Hospital?

Baby's expected due date:

Baby's gender

Boy

Girl

We don't know - it's a surprise

CDH Diagnosis Verification

This can be a letter from your doctor, social worker, etc. explaining the diagnosis (with official letterhead/contact information to verify) or a picture of your hospital patient portal that has your name/baby's CDH information, etc.. Please email us if you have questions about this.

State the full name & email of your social worker for verification:

Expected Length of NICU Stay

I allow the Eden Calhoun Charitable Fund to contact the medical personnel listed above to confirm information as needed.

I consent to providing 1 picture of our family for the ECCF to post on their website and/or social media. It's important for our donors to see the families they're helping!

I agree that all information given on this form is accurate and honest.