+52 5571590179
CDMX, Mexico
Monday - Friday 9:00 - 18:00

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+52 5571590179
CDMX, Mexico
LUN -SHOW 9:00 - 18:00

Application to the FUERSA911 - SHT Program

Transforming Lives through Superior Hyperthermia (SHT)

Please answer all the questions with the data of the requesting patient, all the information obtained in this questionnaire is handled in accordance with our privacy notice that you can consult in our Privacy Policy

1. Personal information

Patient's full name

Age

Gender

Male Female

Civil status

Single Married Divorced Other

Number of children (if applicable)

2. Contact information
Write your contact information completely and correctly. If you are a minor, enter the information of the legal representative or guardian.

Full address

Attach a photo of proof of address such as: Electricity, Telmex, Gas, Water, Property, other.

Contact phone number

3. Academic training
If you are a minor, complete the information of the legal representative or guardian.

Level of study

Master or Doctorate Bachelor's or Technical Degree Baccalaureate Secondary Primary Other

Works

Yeah No

4. Employment status
Complete as detailed as possible.

Current occupation: (describe in detail)

Monthly income

$5,000 to $9,999 $10,000 to $19,999 $20,000 to $29,999 $30,000 to $39,999 $40,000 or more

Employer details

Time at work

5. Income and expenses
If you are a minor, enter the information of the legal representative or guardian.

Total household income

$5,000 to $9,999 $10,000 to $19,999 $20,000 to $29,999 $30,000 to $39,999 $40,000 or more

Monthly expenses (rent, utilities, food, transportation, education, etc.)

Is there other income in the household besides those already mentioned?

6. Health

Does the patient have any health insurance?

YEAH NO

Patient Insurance Type

Social Security (IMSS) Institute of Security and Social Services of State Workers (ISSSTE) Insurance of major medical expenses

7. Medical expenses generated
Amount and description of medical expenses generated in studies, analyses, surgeries, medications or others.

Expense type

Studies Analysis Surgeries Medicines Others

Amount and detailed description

Upload the files mentioned in your previous answer, preferably in PDF or JPEG Image

8. Major Medical Expense Insurance

Name of the Insurer

Type of coverage and/or insured amount

Have you had expenses incurred not covered by your major medical insurance? YES/NO - AMOUNT

9. Housing

Are you a landlord or tenant?

Owner Tenant

Monthly housing cost

Is the current housing adequate for the patient's treatment needs?

Yeah No Maybe

10. Debts
If the patient is a minor, refer to his or her legal representative or guardian.

Does the patient currently have debts?

Yeah No

Briefly describe outstanding debts

11. Support network

Does the patient receive financial support from friends or family?

Yeah No

Do you have any emotional support? (Receive or attend group and/or personal therapy supported by a psychiatrist professional)

Yeah No

Can you count on emotional support from your close network?

Yeah No Maybe

12. Other considerations

Are there any other particular circumstances that affect the patient's financial situation and ability to access therapy?

13. Formats to download, complete, sign, scan and attach
Download: Registration Application

Scan and upload the Registration Request file

14. Sponsorship Request Video
You must record yourself on a video of NO more than 2 minutes where I integrate the following points:

Personal presentation:
Start the video by introducing yourself with your name, age, and a brief description of who you are. Make sure you convey a friendly and genuine impression.

Medical Context:
Explain your current medical situation clearly and concisely. Provides details about the condition you are facing and why superior hyperthermia therapy is essential for your treatment.

Impact on Your Life:
Describe how superior hyperthermia therapy can positively impact your life. Highlight the benefits you hope to gain and how this will make a difference to your overall well-being.

Sponsorship Need:
Honestly explain why you need the sponsorship. Detail the financial challenges you face and how financial support will allow you to continue therapy consistently.

Commitment and Gratitude:
Be sure to express your full commitment to the treatment and your willingness to follow all instructions from the medical team.

Thank you in advance for any support that the foundation can provide, showing your appreciation for the opportunity this represents for your recovery.

Remember to keep the video short and focused, highlighting the authenticity and sincerity of your request. You can use a positive and optimistic tone to convey hope and confidence in the effectiveness of the therapy.

Good luck with your application!

Load video

15. FUERSA team message

We sincerely appreciate your interest in participating in the FUERSA911 Program. Your request is valuable to us and will be carefully analyzed by our team. If accepted, we commit to exploring, to the extent possible, sponsorship opportunities within our network of contacts and allies.

It is important to note that sponsorship is not guaranteed and seeking financial support will depend on the availability of resources at the time of review. This process will be carried out without obligation on the part of any of the participating parties.

We want to assure you that all data provided will be treated with the strictest confidentiality, in accordance with our Privacy Notice for the Handling of Personal Data, which you can consult on our official website: www.fuersamx.org

We appreciate your trust in the FUERSA911 Foundation. We will contact you shortly to inform you about the status of your application. In the meantime, we urge you to remain hopeful and strong on your path to recovery.