Travel Grant Application

Parent/Guardian Information
Parent/Guardian#1 Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Name of your bank*
You must have a bank account to apply for the Travel Grant Program.
Parent/Guardian#2 Name

First NameLast Name
Is the address the same as Parent/Guardian#1?

yes
Parent/Guardian#2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com

Child's Information
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Is the child's address the same as Parent/Guardian#1?

yes
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has your child been diagnosed with a laryngeal cleft?*

YesNo, but I believe he/she has one based on previous medical tests.
What type of cleft has your child been diagnosed with?*

Type 1Type 2Type 3Type 4Not yet diagnosed

Proof of Laryngeal Cleft
I understand a laryngeal cleft cannot be diagnosed by a swallow study, FEES, or flexible in-office scope.*

yes
My child has a laryngeal cleft, as proven by:*

ENT procedure notes that explicitly diagnose a laryngeal cleft and the type. Must be done using a rigid scope while under general anesthesia. Often called a DLB (direct laryngoscopy & bronchoscopy), ML&B (microlaryngoscopy and bronchoscopy), or a triple scope.Other ENT medical notes that prove a laryngeal cleft diagnosis and the type.Signed letter from an ENT on letterhead stating the child's name, date of birth, and the child's diagnoses, including cleft type.My child is not yet diagnosed.
If your child has not yet been diagnosed, please upload:
1. A written summary stating the child's history and any medical treatments, tests, procedures, or therapy conducted so far, as well as why you believe your child has a laryngeal cleft.
2. Documentation proving these treatments/tests/procedures/therapy.
3. Any other diagnoses for the child.
Laryngeal Cleft Documentation*

Please upload PDFs proving your child has a laryngeal cleft.
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Travel for laryngeal cleft medical care
Travel for my child's laryngeal cleft:*

has already occurred within the last 30 daysis planned for the future
Travel dates:*
Please list the doctor's full name. *
Please list the hospital/facilities full name as it appears on their website.*
Doctor/hospital/facility address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Description of medical care scheduled or incurred.
Please let us know what type of care and procedures your child will receive during this trip.
Number of miles from child's home to the medical facility?
Anticipated or incurred travel costs:*

lodginggasairfaretrainbusrideshareOther

Parent Agreement and Certification
I certify and agree to the following:
- I will be traveling primary to obtain medical care for my child's laryngeal cleft.
- I will be traveling at least 100 miles to access the medical care.
- LCN will only reimburse up to $500 of eligible travel expenses.
- I have a financial need.
- LCN will not reimburse other costs, including food.
- LCN will reimburse lodging for only one additional night after hospital discharge or medical appointment, if needed.
- No other individual, insurance company, organization, assistance program, etc. will reimburse or pay for these travel costs.
- LCN will not transmit any reimbursement electronically.
- I have a bank account that I can deposit LCN's reimbursement check into.
- I will submit a photo of my child with a one paragraph travel summary for LCN to use for marketing and promotional purposes. I understand my reimbursement check will not be mailed until I submit the photo and the journey summary.
- I will submit my child's full laryngeal cleft journey within three months of receiving the reimbursement check.
- I will be required to submit medical documentation proving my child received treatment for their laryngeal cleft at the time and location submitted in this application before LCN will issue a reimbursement check.
- I will be required to submit receipts for all incurred travel that matches the dates and locations included in this application. Receipts must include at least the total cost, date, location, business, method of payment, and payment received.
- I will be required to submit all receipts within 30 days of travel in order to receive reimbursement. Receipts submitted longer than 30 days after the travel will not be reimbursed.
- LCN's Travel Grant Program is donor-funded, so my expenses will be reimbursed only if LCN has adequate funding for the program.
- If my application is not approved, I will be advised why and given a reasonable amount of time to correct my application.
- If multiple applications are received by LCN during a grant cycle, those not approved do to lack of funding will automatically be resubmitted the following month.
Signature

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Parent/Guardian Information

Child's Information

Proof of Laryngeal Cleft

Travel for laryngeal cleft medical care

Parent Agreement and Certification