Victory Trip Referral Application Form

Victory Trip® Referral Form
Recipient Personal Information
This form is the first step of the Victory Trip® application process.

Once your form is completed, we will contact your nurse navigator to confirm that you did in fact receive medical treatment for a life-threatening illness. Once confirmed, we will contact you.

Victory Trip Guidelines
- Must be within the ages of 18 to 40.
- Must have battled a life-threatening illness such as cancer and have completed treatment (cancer-free).
- Must have completed treatment (cancer-free). Unfortunately, chronic illnesses do not qualify for a Victory Trip.
- Must be cleared by your doctor to travel.
- Cannot have had trip/experience from another organization.
- Recipient & travel companion must be citizen(s) of the United States
- Must have completed treatment within two years of filling out your application.
For more questions regarding Victory Trips®, view our Frequently Asked Questions. If you don’t qualify for 17 Strong®, please see our list of Other Resources that includes other organizations that may be able to help.

Press "Next," below if the applicant meets the above guidelines and you are ready to continue...

Applicant Contact Information
Name*

First NameLast Name
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Applicant's Date of Birth*

MonthDayYear
Date
Recipient Gender*

MaleFemaleNon-BinaryPrefer not to say
Applicant's Employer
Applicant's Facebook Handle/Username
Applicant's Instagram Handle/Username
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Signature and Acknowledgement

By typing your name below, you are signing this form electronically. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Signature

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Today's Date

MonthDayYear
Date
By pressing "Acknowledge" below, the applicant authorizes 17 Strong® to verify the information listed in this form. Thank you for your application; we look forward to working with you. We will contact you after we review your application. Victory Trips are awarded on a first-come, first-served basis and as funding is available. If you have any questions, don't hesitate to get in touch with us at 805-595-1412

I'm Sorry. You selected an answer that goes against the above guidelines, and therefore are unable to apply.

The Applicant:
- Must be within the ages of 18 to 40.
- Must have battled a life-threatening illness such as cancer and have completed treatment (cancer-free).
- Must have completed treatment (cancer-free). Unfortunately, chronic illnesses do not qualify for a Victory Trip.
- Must be cleared by your doctor to travel.
  Cannot have had trip/experience from another organization.
- Must be a citizen of the United States
- Must have completed treatment within two years of filling out your application.
For more questions regarding Victory Trips®, view our Frequently Asked Questions. If you don’t qualify for 17 Strong®, please see our list of Other Resources that includes other organizations that may be able to help.

Please click the Review button to review your inputs and submit your application!

Thank You!
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