Emily has Congenital Central Hypoventilation. She has a tracheostomy and is ventilator and oxygen dependent. She is being raised by her grandmother. When her grandmother's sister became ill with breast cancer, she used Children Are Precious to go visit her in Texas. She stayed with her sister until she passed away. Something she could have never done without CAP's help.

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Family Information

Child's Name

Mother's Name

Father's Name




Postal Code

Home Phone

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Does child live with both parents?

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Parent 2 Address

Parent 2 City

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Insurance and Income

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Do you receive social security income (SSI)? If yes, list amount

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Father's occupation

Number of children

Please list family obligations or hardships

Child's Medical History

Date of birth (mm/dd/yyyy)

Child's primary care physician

Primary care physician's address and phone number:
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Medical condition


Does your child have home nursing care?

Briefly describe type of assistance and treatments provided by home nursing care

If yes, average hourse per week

If yes, what agency is used?

Hours covered by insurance

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Please indicate how your family would benefit from respite care provided by Children Are Precious.

Please list any support groups your family participates

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