Hunter Health Application Form

Family Information

Please Provide Both Caregivers (If applicable)
Caregiver #1: *

First NameLast Name
Caregiver #2:

First NameLast Name
Email Caregiver #1*
example@example.com
Email Caregiver #2
example@example.com
Phone Number Caregiver #1*
Format: (000) 000-0000.
Phone Number Caregiver #2
Please enter a valid phone number.Format: (000) 000-0000.
Child's Information

(fill out a separate form for each child)
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Diagnosis Details
Primary Care Team or Clinic
How would you describe your child's current healthcare needs?
Support and Services
What areas would you like the most support with? (check all that apply)

Scheduling appointments and remindersNavigating insurance or medical billingFinding specialist and care resourcesCoordinating between multiple providersEmotional or family supportOther
Hunter Health Portal (Coming Soon)
Would you like to be notified when our Hunter Health Portal launches so you can securely manage appointments, documents, and care coordination all in one place?

Yes, please!Not right now.
Anything else you'd like for us to know about your family needs?
I consent to being contacted by Project Alive for the purpose of participating in the Hunter Health Program.*

YesNo
Signature*
Today's Date:*

MonthDayYear
Date
Should be Empty:

Family Information