Request Assistance Form

Appointment Section
Child's Local Doctor's Name
Local Doctor's Phone Number
Please enter a valid phone number.
Out-of-town Doctor's Name
Out-of-town Doctor's Office Phone Number
Please enter a valid phone number.
Out-of-town Hospital/Doctor's Address (*Must be over 1.5 hours travel from home address for us to assist.)

Hospital/Doctor Office Name

Street Address

CityState / Province

Postal / Zip Code
Scheduled Treatments: List each known Cancer Treatment for this month. Funding will be determined, based on the amount of trips taken per month.
Trip Start Date (Date you leave your home and travel for the appointment) *

MonthDayYear
*Doctor paperwork must confirm your dates or file will be marked incomplete! Doctor must note if child has to stay overnight for us to fund.
Separate applications must be completed for each out-of-town trip. List the dates and times for your appointments for THIS trip only. *That means when you leave your home (Start Date) and return to your home (End Date) that is a "Trip" and 1 Application.
How many days?*

Day TripOver Night Stay (Meredith's Miracles can provide lodging only if child has multiple appointments over consecutive days.)More than 2 daysChild Hospitalized (release time TBD, estimated End Date below)Other (Explain in "Trip Details" below)
Trip End Date (Date you will be traveling to return home)*

MonthDayYear
Trip Details *
Please give details about your trip and any other details you need to tell us so that we can assist you better.
Child's Medical Conditions *
Details you would like to share but this is NOT required.

Request Assistance Form

Appointment Section

Each time you travel for medical away from your home we can help! Our 3 step program: Take a picture of this and save on your phone.