New Application

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Primary Contact Parent Information

Child Information

Hospital Information

Additional Family Members

I accept
I accept
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.

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