Travel Request

Please submit our Travel Request to Jack’s Helping Hand by mail, fax, email, or in-person. We require that the Request is received at our office 7-10 business days prior to departure day if traveling to guarantee assistance. If this is an emergency, please contact our office as soon as possible so we can do our best to assist you!





Date of Birth:*
Completed New Child Application?:

If no, please fill out New Child Application on our website or in our office.

Travel Request

Appointment Type:
Other Appointment Type:
Name of Doctor/Hospital:*
Date of Appointment:*
Time of Appointment:*
From (City):*
To (City):*
Date of Departure:*
Date of Return:*


Transportation Type:

*If driving car, please fill out the following:

Car Make:
Car Model:
Car Year:


Are you requesting Lodging?:
Applied to Ronald McDonald House?:
*Lodging is only considered when other non-profit lodging is not available. Requests for lodging must be made to the Ronald McDonald House at least two weeks before appointment. Please contact a Social Worker at the hospital where Child is treated for this referral. If lodging is unavailable, Social Worker will contact us. We defer to hospital’s protocols regarding housing.

Requested:

Check-in Date:
Check-out Date:
Number of people traveling:
Preference:
*Preference not guaranteed.

Acknowledgement

In order to advance financial assistance/gift cards in conjunction in the medical treatment of:

Child Name:

1. The undersigned are parents or legal guardians of the child.

2. Financial assistance provided will be with the use of said funds/gift cards to be specified by Jack’s Helping Hand. Gift cards are to be used on the dates of requested appointments.

3. The undersigned further agree(s) to return any unused funds immediately to Jack’s Helping Hand so that those funds can be utilized by the organization to benefit other families.

4. The undersigned acknowledge(s) and agree(s) to maintain records that will be made available to Jack’s Helping Hand upon reasonable request, detailing the expenditures made with the funds/gift cards provided by the organization.

I have read the guidelines for Requests for Assistance and eligibility checklist stated in New Child Application and I declare that the information furnished on this request form is true and correct to the best of my knowledge.

Acknowledgment of Responsibility signed:*
Parent/Guardian Name:*
Parent/Guardian Signature:*
Acknowledge Signature:
Relationship to Child:*
Other Relationship: