ASHLEY'S HEART FOR RECOVERY - TRAVEL SUPPORT REQUEST APPLICATION

ASHLEY'S HEART FOR RECOVERY - TRAVEL SUPPORT REQUEST APPLICATION

Ashley’s Heart for Recovery honors Ashley Williams’ memory by supporting families navigating the challenges of eating disorder treatment. We provide grants to help cover travel expenses so families can stay connected and present during critical stages of their child’s recovery. By easing the cost of travel, we allow families to focus more fully on healing and support.
Applicant Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Child's Name*

First NameLast Name
Treatment Center Information
Treatment Center Name*
Contact Person at Treatment Center*
Prior to submitting this application, please let this contact person know that someone from Ashley's Heart for Recovery will be contacting them to verify that your child is currently receiving residential treatment. They may require you to sign their release, in addition to the one you will electronically sign on this application.
Contact Person Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Contact Person Email*
example@example.com
Treatment Center Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Admission Date*

MonthDayYear
Date
Expected Length of Stay (if known)
TRAVEL ASSISTANCE REQUEST
We are currently offering up to $500 per family to assist with travel to and from your child's treatment center, hotel stay, and incidentals. This amount is based on the average price of a two night stay in a hotel along with a Visa gift card for incidentals. The monetary amount awarded may vary depending on the number of applications received at any given time.
Date(s) you will be traveling to visit your child in treatment. *
BRIEF STATEMENT OF NEED
Please describe why this travel assistance is needed and how your visit will help support your child during treatment. (100–300 words)*
ADDITIONAL INFORMATION (optional)
Is there anything else you’d like to share with Ashley’s Heart for Recovery?
PRIVACY STATEMENT
All information submitted in this application will be kept confidential. Ashley’s Heart for Recovery will not share your personal information except:

- To verify that the patient is currently a residential client with the treatment center (as authorized below)

- When required by law

- To share anonymized insights with donors and supporters (no identifying information will be used without explicit written permission)
CONSENT TO CONTACT TREATMENT CENTER
ACKNOWLEDGEMENTS
LIABILITY WAIVER
By signing below, I release Ashley’s Heart for Recovery and its officers, directors, and volunteers from any and all liability arising from the use of any assistance provided. I understand Ashley's Heart for Recovery is not responsible for the quality, safety, or experience of third-party vendors such as hotels or gift card issuers.
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ASHLEY'S HEART FOR RECOVERY - TRAVEL SUPPORT REQUEST APPLICATION

Applicant Information

Treatment Center Information

TRAVEL ASSISTANCE REQUEST

BRIEF STATEMENT OF NEED

ADDITIONAL INFORMATION (optional)

PRIVACY STATEMENT

CONSENT TO CONTACT TREATMENT CENTER

ACKNOWLEDGEMENTS

LIABILITY WAIVER