Family Application - Miracle Travel Works

Eligibility Requirements: To receive financial assistance from Miracle Travel Works, Inc. (MTW), families MUST be traveling for the purpose of seeking urgent medical treatment for their children’s serious ailments or injuries, age birth through 18 years old, and must have their main residence within the Midwest states, including North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri, Arkansas, Wisconsin, Illinois, Michigan, Indiana, and Ohio. We will offer reimbursement for up to 3 months after the initial travel date, but by applying prior to travel you can help to ensure that money is reserved for your expenses in advance. You must provide itemized receipts to be refunded for travel expenses. Please feel free to email applications@miracletravelworks.org with any questions you may have when filling out the application.

Please thoroughly fill out each section, an incomplete application will result in delays.

If you already have an account and username with us, login here.

Username^*

Password^*

Password must be at least 7 characters long.

Enter password again^*

Primary Contact Parent Information

First Name^*

Last Name^*

Street Address^*

City^*

State^*

Zip Code^*

Phone^*

Email^*

Relationship to Child^*

Child Information

Child's First Name^*

Child's Last Name^*

Birth Date^*

Age (years)^*

Description of Illness or Injury^*

Description of Treatment Needed^*

Travel details (trip duration, please estimate if not known)

Please list any website that is being used to document patient's experience (i.e: caringbridge.org, facebook, carepages.com)

Hospital Information

Hospital Name

Hospital Street Address

City, State, Zipcode

Name of Hospital Contact Person

Position

Contact's Phone

Additional Family Members

Please list any other family members that may travel with the patient. Please include name, age, and relationship to patient.

Is there any other information you would like to share?

Liability Waiver^*

I accept

I/WE AGREE TO RELEASE Miracle Travel Works, Inc. FROM ANY AND ALL CLAIMS FOR PERSONAL INJURY AND/OR PROPERTY DAMAGE, LIABILITIES, OBLIGATIONS, PREMISES LIABILITY, RIGHTS, DEMANDS, ACTIONS, DUTIES, CONTROVERSIES, PROMISES, DEBTS, LIENS, CAUSES OF ACTION, LOSSES, COSTS AND EXPENSES OF ANY KIND AND EVERY KIND, NATURE, AND CHARACTER, KNOWN OR UNKNOWN AND DEMANDS OF EVERY KIND AND NATURE, KNOWN AND UNKNOWN, INCLUDING, BUT NOT LIMITED TO, ATTORNEYS FEES AND COSTS, ARISING FROM OR RELATED TO PARTICIPATION IN THE Miracle Travel Works programs. THIS INCLUDES, BUT IS NOT LIMITED TO, ALL LIABILITY FOR DAMAGES AND INJURIES TO BOTH PERSONS AND PROPERTY BROUGHT ABOUT, CAUSED BY OR STEMMING FROM, THE ACTIVE OR PASSIVE NEGLIGENCE OF ANY OR ALL OF THE RELEASED PARTIES.

Photo Release

I accept

I hereby consent to and authorize the use and reproduction by Miracle Travel Works of all photography and/or other audiovisual materials taken of me/my son/my daughter/my family, for promotional printed material, educational activities, exhibitions, or for any other use for the benefit of the organization.

Upon receiving the donation, we require you to send a brief testimonial about your experience working with Miracle Travel Works and we would appreciate a picture of the child for use on our website or other marketing material. This will help us to encourage future donations and allow us to help additional families. Thank You, The Miracle Travel Works Board

Estimated Expense Information

Please estimate all applicable travel expense.

Plane Ticket(s): $

Gas: $

Lodging: $

Food: $

Other travel expenses, please describe (examples=rental car, hospital parking): $

If you have additional expenses to add here, please provide a description of what they are for.

Total Amount of Expense Reimbursement Being Requested: $

Please attach any important documents that will help in evaluating this request. If your travel is already complete, feel free to attach receipts, however they are not required at the time of application.

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