Request Assistance Form

Requester's Name *

First Name Last Name Relation to child

We request 2 weeks notice before your trip unless this is deemed an unexpected medical trip.*

I will submit my application and get proof of appointment faxed or emailed 2 weeks prior to my child's planned appointments.This is deemed an UNEXPECTED medical trip. I did NOT have 2 weeks notice.

If you have a social worker please provide their name, phone number & hospital name.

Social Workers Name Phone Number Hospital Name

What town is your baby currently in the NICU? (PICU, RNICU)

What was your baby's original due date?*

Date

Please share any other details or medical information about your child so that we can assist you better. *

Where will you be staying while you're out of town?*

Ronald McDonald House1 night in a Hotel (appointment must be before 9:00 am for Surgery, Lab work or other special circumstances)In Hospital with Child (Doesn't need lodging)Do Not need lodging with our trip.

4 Steps MUST be completed for Meredith's Miracles to assist your child EVERY TIME we fund a trip. *Check ALL boxes to acknowledge that you must complete the following steps every time we assist your child. ~Your child's file will be placed on HOLD until information is received.*

1. This "Apply for Assistance Form"; this must be completed for EACH out-of-town trip. (Note: NICU Families fill out a form once a month with confirmation that your baby is still in the hospital.)2. Proof from Doctor or Social Worker for your child's appointment/surgery/hospital stay MUST be submitted before we can help you. This can be attached below or sent via email/fax. (*Applications will not be processed without this information. We may contact your doctor/social worker if additional verification is needed.)3. Photo of your Drivers License to be attached below or sent via email/fax. Drivers license must match recipients name to receive funding. (*We only need this one time for your child's file. For future applications do not submit your drivers license.)4. After the funded trip you MUST send confirmation you attended your appointment via email/fax. (i.e., A simple school excuse from the hospital or doctors office) *Doesn't apply for NICU Families. NOTE: Write down the email/fax number now. Once you submit this form you will no longer be able to view this information. Email: info@meredithsmiracles.org Fax: 334-222-2867

~Upload Photo of your Drivers License~ Note: You will not be funded until we have your Drivers License. It must match the recipients name to receive funding. Attach photo below or send via email (info@meredithsmiracles.org) or fax (334-222-2867) *We only need this one time for your Child's file.

~Upload your Appointment/Surgery/Hospitalization Proof from Doctor or Social Worker~ Must include the following info: Child's name, Date & Time of appointments, Proof of hospitalization. This MUST be submitted before we can provide help.Attach below or send via email (info@meredithsmiracles.org) or fax (334-222-2867). (*Social Workers will send us this info directly if you ask them.)

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~Confirmation you attended your last appointment~ If you have NOT provided confirmation that your child attended the LAST TRIP we funded, please attach it below or send via email (info@meredithsmiracles.org) or fax (334-222-2867).(*Note: A simple school excuse from the hospital or doctors office will suffice. If we don't have this, funding may be denied.)

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Today's Date*

Date

Signature*

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Request Assistance Form

Appointment Section

Each time you travel for medical away from your home we can help! Our 2 step program: Take a picture of this and save on your phone.