Application Form — Schools for PANDAS

*Please note that applicants will be chosen based on financial need

APPLICANT INFORMATION

Name

First Name

Last Name

Date

YYYY

Date of Birth

YYYY

Relationship to IVIG Recipient

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

IVIG RECIPIENT INFORMATION

*If you are applying for yourself, please still complete the following questions

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age

Phone

(###)

###

####

Year of PANS/PANDAS Diagnosis

Age of PANS/PANDAS Diagnosis

Treatments Attempted Prior to IVIG

IVIG Treatments Received Since Diagnosis

Name of Diagnosis/Treating Physician

First Name

Last Name

Physician's Affiliated Institution, If Applicable

Physician's Phone

(###)

###

####

Physician's Email

INSURANCE INFORMATION

Please select one of the following

Name of Insurance

Policy Number

Please select one of the following:

Name of Policyholder

First Name

Last Name

FINANCIAL INFORMATION

Parent/Guardian 1's Job

Parent/Guardian 1's Level of Education

Parent/Guardian 2's Job

Parent/Guardian 2's Level of Education

IVIG Recipient's Job, If Applicable

IVIG Recipient's Level of Education

Net Income

If chosen as IVIG recipient, I agree to provide proof of income if requested, such as tax returns

I agree

I do not agree