New Application RM_StatsUsername *Password *Password must be at least 7 characters long.Enter password again *Primary Contact Parent InformationFirst Name *Last Name *Street Address *City *State *Zip Code *Phone *Email *Relationship to Child * Child InformationChild'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 InformationHospital NameHospital Street AddressCity, State, ZipcodeName of Hospital Contact PersonPositionContact's Phone Additional Family MembersPlease 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 acceptI/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 ReleaseI acceptI 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 InformationPlease 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. Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu.
