Shadow Jumpers Family Assistance Application

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

CityState

Zip CodeCountry
Name of primary photosensitive family member*

First NameLast Name
Their date of birth *

MonthDayYear
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 EruptionSolar UrticariaActinic 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 NameLast Name
Their date of birth

MonthDayYear
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 EruptionSolar UrticariaActinic 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 NameLast 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*

MonthDayYear
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 tripRe-doing a failed experience that is sun relatedHome renovation and modificationFinancial relief related to photosensitive medical bills and related expensesOther
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?*

YesNoI 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 NameLast Name
Family Member 1 Date of Birth

MonthDayYear
Date
Relation to photosensitive individual(s)
Family Member 2

First NameLast Name
Family Member 2 Date of Birth

MonthDayYear
Date
Relation to photosensitive individual(s)
Family Member 3

First NameLast Name
Family Member 3 Date of Birth

MonthDayYear
Date
Relation to photosensitive individual(s)
Family Member 4

First NameLast Name
Family Member 4 Date of Birth

MonthDayYear
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.

Cancelof
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
Should be Empty:

Family Assistance Application