Travel Request Test

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!
MM slash DD slash YYYY
If no, please fill out New Child Application on our website or in our office.

Travel Request

MM slash DD slash YYYY
MM slash DD slash YYYY
*If driving car, please fill out the following:
*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.


MM slash DD slash YYYY
MM slash DD slash YYYY
*Preference not guaranteed.


In order to advance financial assistance/gift cards in conjunction in the medical treatment of:
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.
MM slash DD slash YYYY
Acknowledge Signature:
<!– was id=5 –>