Application for Minor to Seek Medical Care in the United States of America.

Application for Minor To Seek Medical Care in the United States of America.

This effort is being coordinated through the effort of Doctor's Against Genocide: https://doctorsagainstgenocide.org/
Patient Name*

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
Patient Sex*

MaleFemale
Passport or ID Number*
Select All the Reason why the treatment is medically necessary and unavailable in the patient's country:*

The necessary medications for treatment are not available.The necessary resources for recovery and rehabilitation are not available.The necessary emotional, social, and psychological support are not available.Complex surgical interventions are not available.The necessary interdisciplinary care team model is not available.Other
Please share meaningful information that may help this child get necessary care

Status of Child and Any Surviving Members of Family

	Alive	Deceased	Missing
Patient's Mother or Father
Patient's Uncle/Aunt
Patient's Adult Sibling/Cousin

Which US State and City do have a potential sponsor for the child in need of medical care? *
Attach Passport Copy, Government Identification, or Identification of Patient

Cancelof
Upload Medically Relevant Images
Name of Child's Guardian*

First NameLast Name
Mobile Number of Child's Guardian*
Email of Child's Guardian*
example@example.com
Name of Non-Profit that Provided Medical Care to Child*

FAJR ScientificPAMAMedGlobalRahma WorldwideSAMSOther
Geolocation of Where This Form is Filled*
Please verify that you are human*
Name of United States Government Official Willing to support medical care of at least 1 child within his or her district?

Shri Thanedar (13th District of Michigan)Other
To suggest names of other public representatives wiling to join Shri Thanedar, please submit their names using this form:

https://form.jotform.com/241146225960150
Date Form is completed
Signature

Clear
What to Expect Next:

Although arranging medical care cannot be guaranteed, the objective is to make every effort to do so.

Once the application is submitted, it will undergo a review process to identify sponsors for medical care. This process will include collaboration with government officials, healthcare systems, medical providers, and civilian volunteers. Together, they will aim to manage costs, logistics, and provide the essential support needed to offer medical treatment to a child who has been injured.

The following information will be needed:
- DS-160 Nonimmigrant Visa Application
- Payment of Application Fee of $185
- Reciprocity Fee
- Photo
- Passport
- Documents Showing Purpose of Trip
- Letter from Sponsor
- Form I-134 Affidavit of Support
- Interview prior to travel
Should be Empty:

Application for Minor To Seek Medical Care in the United States of America.

To suggest names of other public representatives wiling to join Shri Thanedar, please submit their names using this form:

https://form.jotform.com/241146225960150

What to Expect Next: