Flutter Club, inc. Travel Assistance Form

Flutter Club, inc.

Travel Assistance Application
Eligible individuals may receive financial assistance for transportation on The Flutter Express to Boston or New York City.

Flutter Club, inc. provides financial assistance specifically for travel on The Flutter Express. This is a non-emergency, non-medical transportation service, comparable to a traditional motor coach bus used for commuting or entertainment purposes.

Please note:
- The Flutter Express is not an ambulance, ambulette, or medical transport vehicle.
- It does not include onboard medical personnel, treatment services, or medical equipment.
- Riders must be medically stable and able to travel independently or with a caregiver or companion.
To be eligible for financial assistance from Flutter Club, inc., applicants must meet all of the following criteria:

Residency Requirement
Must reside in one of the following counties:
- New York: Albany, Columbia, Essex, Fulton, Greene, Hamilton, Montgomery, Otsego, Oneida, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington
- Massachusetts: Berkshire
- Vermont: Bennington, Windham
Medical Eligibility

Applicants must have a confirmed diagnosis or medical need from an accredited medical center and be referred by that institution’s licensed clinical advocate or medical staff member.

Eligible medical conditions include one of the following:
- A confirmed critical illness
- A confirmed developmental disability
- A confirmed reproductive or fertility-related condition or need
- A medically indicated need for a second opinion related to any of the conditions listed above.*
*If applicant requires travel assistance for a second opinion before official confirmed diagnosis, Flutter Club, inc. will financially assist for up to two rides on The Flutter Express. Please indicate this need in the application below.

Required Documentation
- A signed referral from the patient’s treatment center by a licensed clinical advocate (e.g., social worker, nurse navigator, or physician).
- A completed application signed by the patient or legal guardian and properly attested.
Important Application Information

Submitting an application does not guarantee approval. All assistance is subject to availability of funds and program capacity. Flutter Club, inc. reserves the right to request additional documentation, deny applications that do not meet eligibility criteria, or modify program terms at any time.
Applicant Information

If under 18 years of age, please complete as legal guardian on behalf of the applicant.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age at time of application*
Mobile Number*
Please enter a valid phone number.
Home Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Have you lived at this address for at least 6 months?*

YesNo
Companion/Caregiver/Family Member Information

The person that will be traveling with the applicant and helps with care.
Companion/Caregiver/Family Member Name

First NameLast Name
Companion/Caregiver/Family Member Phone Number
Please enter a valid phone number.
Companion/Caregiver/Family Member Relationship to the Applicant
Secondary Family Member Name. If Applicant is under 26 years of age, a second family member may travel with them. Please include their name below.

First NameLast Name
If Applicant is under 26 years of age, please indicate second family member's relationship to the applicant.
Will a sibling, child, or other family member under the age of 18 need to travel with the applicant?

yesNo
If yes, Please include the name of sibling, child, or other family member under the age of 18 that needs to travel with the applicant.

First NameLast Name
Relationship to applicant (for sibling, child, or other family member under 18):

ChildSiblingOther
Please indicate age of child, sibling, or other family member under the age of 18.
Applicant Transportation Acknowledgement
Please read the following carefully and check the box to confirm your understanding:*

I acknowledge and understand that The Flutter Express is a non-emergency, non-medical transportation service. It is not an ambulance, ambulette, or medical transport vehicle. There are no medical personnel, equipment, or treatment services on board. I certify that I (or the applicant for whom I am applying) am medically stable and able to travel independently or with the support of a caregiver or companion who can provide necessary assistance throughout the trip.
Volunteer Companion Support
If you are traveling alone, Flutter Club, Inc. may be able to pair you with a volunteer companion to accompany you on your journey aboard The Flutter Express. Please select one:*

Yes, I am traveling alone and would like to be considered for a volunteer companion to travel with me.No, I do not require a volunteer companion at this time.Unsure – please contact me to discuss.
Confirmed Critical Illness or Developmental Disability Diagnosis

Please complete this section for Critical Illness or Developmental Disability Only
Applicant's Diagnosis
Applicant's Diagnosis Subtype (if applicable)
Date of Diagnosis Applicant is currently being treated for:

MonthDayYear
Date
How often will the Applicant need to travel in 2025 to New York City or Boston?*

1-3 trips4-7 trips8-11 trips12 or more trips
If seeking healthcare in NYC, which facility will the applicant be going to?*

Memorial Sloan Kettering Cancer CenterNYP- Weill Cornell Medical CenterHospital for Special SurgeryMount SinaiColumbia University Irving Medical CenterOther
If you chose "other," please indicate NYC healthcare facility below:
type n/a if not applicable
If seeking healthcare in Boston, which facility will the applicant be going to?

Dana Farber Cancer InstituteBoston Children's HospitalBrigham & Women's HospitalBeth Israel Deaconess Medical CenterOther
If you indicated "other," please indicate Boston healthcare facility below:
Type n/a if not applicable
Is the applicant a patient of New York Oncology Hematology (NYOH) and have they applied for travel assistance through the NYOH Community Cancer Care Foundation?*

Yes, I am a patient of NYOH and I receive assistanceYes, I am a patient of NYOH and I was not eligible for assistanceYes, I am a patient of NYOH, I have not applied for assistance, and would like more informationNo, I am not a patient of NYOH
Is the applicant a patient of CR Wood Cancer Center or any of their affiliated locations and have they applied for travel assistance through them?*

Yes, I am a patient of CR Wood Cancer Center or one of their affiliates and I receive assistanceYes, I am a patient of of CR Wood Cancer Center or one of their affiliates and I was not eligible for assistanceYes, I am a patient of CR Wood Cancer Center or one of their affiliates, I have not applied for assistance, and would like more informationNo, I am not a patient of CR Wood Cancer Center or one of their affiliates
Is the applicant a blood cancer patient currently receiving financial assistance through Wicklund Warriors?*

Yes, I am a blood cancer patient and receiving financial assistance through Wicklund WarriorsYes I am a blood cancer patient, but I am not receiving financial assistance through Wicklund WarriorsNo, but I am a blood cancer patient and would like more informationNo, I am not a blood cancer patient
Reproductive Healthcare & Fertility Diagnosis or Need

Please complete this section for Reproductive Healthcare & Fertility only
Applicant's Confirmed Diagnosis or Fertility Need
Applicant's Diagnosis Subtype (if applicable)
Date of Diagnosis Applicant is being treated for

MonthDayYear
Date
If applicant does not have a confirmed diagnosis. Please explain the healthcare need.
How often will the Applicant need to travel in 2025 to New York City or Boston?

1-3 trips4-7 trips8-11 trips12 or more trips
If seeking healthcare in NYC, which facility will the applicant be going to?

Memorial Sloan Kettering Cancer CenterNYP- Weill Cornell Medical CenterHospital for Special SurgeryMount SinaiColumbia University Irving Medical CenterOther
If you chose "other," please indicate NYC healthcare facility below:
type n/a if not applicable
If seeking healthcare in Boston, which facility will the applicant be going to?

Dana Farber Cancer InstituteBoston Children's HospitalBrigham & Women's HospitalBeth Israel Deaconess Medical CenterBoston IVFOther
If you indicated "other," please indicate Boston healthcare facility below:
type n/a if not applicable
Is the applicant a patient of New York Oncology Hematology (NYOH) and have they applied for travel assistance through the NYOH Community Cancer Care Foundation?*

Yes, I am a patient of NYOH and I receive assistanceYes, I am a patient of NYOH and I was not eligible for assistanceYes, I am a patient of NYOH, I have not applied for assistance, and would like more informationNo, I am not a patient of NYOH
Is the applicant a patient of CR Wood Cancer Center or any of their affiliated locations and have they applied for travel assistance through them?*

Yes, I am a patient of CR Wood Cancer Center or one of their affiliates and I receive assistanceYes, I am a patient of of CR Wood Cancer Center or one of their affiliates and I was not eligible for assistanceYes, I am a patient of CR Wood Cancer Center or one of their affiliates, I have not applied for assistance, and would like more informationNo, I am not a patient of CR Wood Cancer Center or one of their affiliates
Is the applicant a blood cancer patient currently receiving financial assistance through Wicklund Warriors?*

Yes, I am a blood cancer patient and receiving financial assistance through Wicklund WarriorsYes I am a blood cancer patient, but I am not receiving financial assistance through Wicklund WarriorsNo, but I am a blood cancer patient and would like more informationNo, I am not a blood cancer patient
Second Medical Opinion

If applicant does not have a confirmed diagnosis and needs to travel for a second opinion only
Indicate Medical Need For Second Opinion Below
Date of Initial Appointment

MonthDayYear
Date
Flutter Club, inc, will financially support up to two rides on The Flutter Express for a second opinion. How many rides will the applicant need?

1 trip2 trips
If seeking healthcare in NYC, which facility will the applicant be going to?

Memorial Sloan Kettering Cancer CenterNYP- Weill Cornell Medical CenterHospital for Special SurgeryMount SinaiColumbia University Irving Medical CenterOther
If you chose "other," please indicate NYC healthcare facility below:
If seeking healthcare in Boston, which facility will the applicant be going to?

Dana Farber Cancer InstituteBoston Children's HospitalBrigham & Women's HospitalBeth Israel Deaconess Medical CenterBoston IVFOther
If you indicated "other," please indicate Boston healthcare facility below:
Is the applicant a patient of New York Oncology Hematology (NYOH) and have they applied for travel assistance through the NYOH Community Cancer Care Foundation?*

Yes, I am a patient of NYOH and I receive assistanceYes, I am a patient of NYOH and I was not eligible for assistanceYes, I am a patient of NYOH, I have not applied for assistance, and would like more informationNo, I am not a patient of NYOH
Is the applicant a patient of CR Wood Cancer Center or any of their affiliated locations and have they applied for travel assistance through them?*

Yes, I am a patient of CR Wood Cancer Center or one of their affiliates and I receive assistanceYes, I am a patient of of CR Wood Cancer Center or one of their affiliates and I was not eligible for assistanceYes, I am a patient of CR Wood Cancer Center or one of their affiliates, I have not applied for assistance, and would like more informationNo, I am not a patient of CR Wood Cancer Center or one of their affiliates
Is the applicant a blood cancer patient currently receiving financial assistance through Wicklund Warriors?*

Yes, I am a blood cancer patient and receiving financial assistance through Wicklund WarriorsYes I am a blood cancer patient, but I am not receiving financial assistance through Wicklund WarriorsNo, I am not a blood cancer patientNo, but I am a blood cancer patient and would like more information
Healthcare Center Information

To be completed by a Clinical Licensed Advocate or similarly credentialed medical professional.
Healthcare Center Location*
Prescribing Doctor*
Heathcare Center Clinician*
Healthcare Center's Clinician Email*
example@example.com
Clinician's phone number*
Please enter a valid phone number.
Medical Provider Certification

If this application is being completed by the applicant independently and not in coordination with a licensed clinical advocate or similarly credentialed medical professional, Flutter Club, Inc. will forward the application to the designated provider to complete the Medical Provider Certification section below. Please proceed with completing the remaining sections: Applicant Attestation and Media Usage Policy and Consent.
Medical Provider Certification

I hereby certify that the applicant has a confirmed diagnosis or medical circumstance meeting the eligibility criteria, including critical illness, developmental disability, reproductive or fertility-related healthcare needs, or the need for a second medical opinion related to one of these areas. I also confirm, to the best of my professional judgment, that the applicant is medically stable and able to travel aboard The Flutter Express, a non-emergency, non-medical motor coach transportation service.
Clinician's Signature

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Date

MonthDayYear
Date
Name of Clinician

First NameLast Name
Applicant Attestation
To be eligible for financial support through Flutter Club, inc., all applicants (or their legal guardians) must review and sign the following attestation. This document is a legal affirmation of the truthfulness of the information provided and the intended use of any financial aid granted. It must be submitted in full as part of the application process.

Applicant Attestation
I, the undersigned applicant (or legal guardian of the applicant), do hereby attest and affirm the following:

Accuracy of Information
I declare that all statements and information provided in this application for financial assistance are true, complete, and accurate to the best of my knowledge. I understand that knowingly providing false or misleading information may result in denial or revocation of assistance and may be subject to legal action under applicable laws.

Use of Funds
I agree that any financial support received from Flutter Club, inc. will be used solely for the purpose(s) outlined in this application, specifically for costs related to non-emergency transportation to accredited healthcare institutions. I understand and accept that Flutter Club, inc. reserves the right to request documentation verifying the appropriate use of these funds at any time.

Proof of Residency
I certify that I have resided continuously for no less than six (6) months in one of the following eligible counties:

New York: Albany, Columbia, Delaware, Dutchess, Essex, Fulton, Greene, Hamilton, Herkimer, Montgomery, Otsego, Oneida, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington
Massachusetts: Berkshire, Franklin, Hampshire
Vermont: Bennington, Windham

Medical Eligibility

I confirm that I (or the individual on whose behalf I am applying) meet at least one of the following criteria, as documented by a Clinical Licensed Advocate affiliated with an accredited medical facility:
- A confirmed critical illness,
- A confirmed developmental disability
- A confirmed reproductive health or fertility-related need, or
- A medically indicated need for a second opinion related to any of the conditions listed above.
Consent to Verification
I acknowledge that Flutter Club, Inc. may request documentation to verify my eligibility and the use of funds or travel.
Signature of the Applicant*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Name of Applicant or Parent/Legal Guardian if Applicant is Under 18 years of age*

First NameLast Name
Flutter Club, Inc. – Media Usage Policy & Consent Form

Sharing Stories with Purpose
Flutter Club, inc. relies on the generosity of donors and sponsors to support individuals and families needing a second medical opinion or navigating critical illness, developmental disabilities, and reproductive health and fertility challenges. Sharing the real stories of those we serve helps our supporters understand the impact of their contributions. This connection is essential to our mission and continued funding. As part of receiving financial support from Flutter Club, inc., we kindly request your permission to feature your healthcare journey in our social media, marketing materials, donor communications, and event presentations. By allowing us to share your story, you help us raise awareness, foster compassion, and inspire continued support. What You’re Agreeing To By signing this consent, you grant Flutter Club, inc. permission to:
- Use photographs and/or videos of you and/or your family, taken with your knowledge.
- Share your story (in part or in summary) on our social media platforms, printed materials, website, and fundraising campaignsUse these materials for marketing, advocacy, or promotional purposes
Important Notes: We will never use your full name or share specific medical details without your consent. Your decision to provide or withhold consent does not impact your eligibility for support.
Consent Acknowledgment: I understand and agree to the above Media Usage Policy.*

Yes, I give permission to Flutter Club, Inc. to use my story, photos, and/or videos as described above.No, I do not give permission.
Facebook Name (if you would like to be tagged/linked to a social media post)
Instagram Name (if you would like to be tagged/linked to a social media post)
Email: applications@flutterclub.com

Address: 10 Greenwood Drive, Unit 10

East Greenbush, NY 12061

Learn more: www.flutterclub.com

Facebook and Instagram @flutterclubinc

© 2025 Flutter Club, inc. All rights reserved.
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Flutter Club, inc.

Applicant Information

Companion/Caregiver/Family Member Information

Applicant Transportation Acknowledgement

Volunteer Companion Support

Confirmed Critical Illness or Developmental Disability Diagnosis

Reproductive Healthcare & Fertility Diagnosis or Need

Second Medical Opinion

Healthcare Center Information

Medical Provider Certification

Applicant Attestation

Flutter Club, Inc. – Media Usage Policy & Consent Form