Family Assistance Application
All applications are reviewed and individually considered by Shadow Jumpers on a rolling basis. Shadow Jumpers reserves the right to make selections and decisions based on factors it deems appropriate and in the best interest of the organization. Those factors may include but are not limited to cost, logistics, budget, timing, quality, and impact of experience. Not all requests will be approved. Accepted families may be asked to provide Shadow Jumpers with more detailed information before continuing in the application process.
Family Name
*
Ex: The McKillops or The Stuhlsatz Family
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Name of primary photosensitive family member
*
First Name
Last Name
Their date of birth
*
-
Month
-
Day
Year
Date
Is the photosensitive family member diagnosed with one of the following conditions?
*
Erythropoietic Protoporphyria (EPP)
Xeroderma Pigmentosum (XP)
Congenital Erythropoietic Porphyria (CEP)
Polymorphic Light Eruption
Solar Urticaria
Actinic prurigo (AP)
None of the above
If you selected NONE OF THE ABOVE, please provide the name of the photosensitive condition or the appropriate context below.
On average, how long can this photosensitive family member be exposed outside before they start to have a full blown reaction?
*
Ex: 15 Minutes
Do you have a second photosensitive family member? Click here if so
Name of 2nd photosensitive family member
First Name
Last Name
Their date of birth
-
Month
-
Day
Year
Date
Is the 2nd photosensitive family member diagnosed with one of the following conditions?
Erythropoietic Protoporphyria (EPP)
Xeroderma Pigmentosum (XP)
Congenital Erythropoietic Porphyria (CEP)
Polymorphic Light Eruption
Solar Urticaria
Actinic prurigo (AP)
None of the above
If you selected NONE OF THE ABOVE, please provide the name of the 2nd photosensitive condition or the appropriate context below.
On average, how long can this 2nd photosensitive family member be exposed outside before they start to have a full blown reaction?
Ex: 15 Minutes
In the event you have more than two photosensitive members in your family, please make note of that in the comment section at the bottom of your application. If accepted, a team member will reach out to get that detailed information.
Head of Household's Full Name
*
First Name
Last Name
Head of Household's Email Address
*
example@example.com
Head of Household's Primary Phone Number
*
Please enter a valid phone number.
Head of Household's Date of Birth
*
-
Month
-
Day
Year
Date
In as much detail as you can, please share information about your family background, the experience of living together with this photosensitive condition, and how the primary family member(s) affected by it is managing their unique circumstances.
*
Head of Household's relationship to this photosensitive family member(s)
*
Ex: Mother
Requests made by Shadow Jumpers usually fit into one of the categories listed below. Please choose the category that best matches your request.
*
Creating a sun proof experience or trip
Re-doing a failed experience that is sun related
Home renovation and modification
Financial relief related to photosensitive medical bills and related expenses
Other
Please provide a detailed explanation of the assistance you are looking for. This will help us understand your needs better and ensure we can provide the most effective support. Additional documents can be upload at the bottom of this application
*
Please note we can only do one request per family.
Is there a deadline for this request, or does it need to occur on a specific date or during a particular time of year?
*
Yes
No
I dont know at this time
If you said YES to the above question please explain
Ex: Trip needs to be in the summer when the kids are off from school
Other Family Members' Basic Information. Click Here
Please provide the names, date of births and additional information for the family members who are not photo sensitive or the head of household
Please stick to immediate family members only. If you would like to suggest including additional outside people (or have more immediate family than the slots provided), please make note in the comment section at the bottom of this application.
Family Member 1
First Name
Last Name
Family Member 1 Date of Birth
-
Month
-
Day
Year
Date
Relation to photosensitive individual(s)
Family Member 2
First Name
Last Name
Family Member 2 Date of Birth
-
Month
-
Day
Year
Date
Relation to photosensitive individual(s)
Family Member 3
First Name
Last Name
Family Member 3 Date of Birth
-
Month
-
Day
Year
Date
Relation to photosensitive individual(s)
Family Member 4
First Name
Last Name
Family Member 4 Date of Birth
-
Month
-
Day
Year
Date
Relation to photosensitive individual(s)
Media Release Statement
*
If our application is accepted, our family agrees to let Shadow Jumpers use our basic family information (family name and home state/country) in addition to any images and quotes from the assistance experience, whether in a screenshot, photo, or as a recording, for purpose including but not limited to enduring archived recording and/or transcript of the assistance experience, marketing and/or promotions
If you wish to include photos or documents with your request, you can submit them here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Feel free to add any extra comments in the space provided below.
I certify that the above information I have inputed and selected is true to the best of my knowledge and belief and I understand that I subject my family's application to being denied and myself to legal action in the event that the above facts are found to be falsified.
*
Yes
Submit
Should be Empty: