• Bridge the Distance Application for Travel & Lodging Assistance

  • Bridge the Distance Fund helps adult cancer patients with the cost of traveling for treatment. This application is short by design. Your eligibility is confirmed by a social worker or doctor at the hospital where you're treated, using the separate certification form we provide — so you don't need to send us any medical records or diagnosis details.

    A social worker, patient navigator, or family member is welcome to help you complete this. You are also able to save your progress and return to complete it later.

    Questions? Email connect@bridgethedistance.org  

  • Patient Information

  • Demographic information is collected below to help us tailor programs and resources to our unique patients, build partnerships, and secure funding to grow our ability to assist patients. Demographic information will only be used in group form. You will not be identified personally.

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Race and Ethnicity (check all that apply)*
  • Format: (000) 000-0000.
  • May we text you?*

  • Travel Assistance Request

  • We cover future treatment-related travel and lodging. We do not cover food, medical costs, or lost wages. Grants are typically $500–$1,500 TOTAL and are awarded based on your cost request. See our Travel Assistance Guidelines for more detail.

  • Start date of appointment*
     - -
    2 digit month, 2 digit day, 4 digit year
  • End date of appointment (if multiple days)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient is requesting assistance with the following expenses (check all that apply)*
  • Have you received or applied for assistance from another organization for this trip?*

  • Patient Care Team Information

  • The patient's will need to be confirmed by a member of the patient's care team at the treating hospital. If you provide a care team member email below, the Care Team Certification form will be automatically sent to them. If you do not have a care team member email, you will be given the link to the Care Team Certification form to send to your care team.

  • Care team member role*
  • Format: (000) 000-0000.

  • Certification and Authorization

  • Do you have a personal, family, financial, or professional relationship with a Bridge the Distance Fund team member?*

  • Please read each statement below carefully and review the following documents related to patient eligibility and eligible expenses.

    • Financial Need Guidance
    • Travel Assistance Guidelines
  • I certify that I am 18 years or older.*
  • I certify that I have not received assistance from Bridge the Distance Fund in the last 12 months.*
  • I certify that I have, or am being evaluated for, a cancer diagnosis and am traveling for diagnostic evaluation, active treatment, or ongoing cancer surveillance/follow-up care.*
  • I certify that the care I am seeking, or the specialized expertise required for that care, is not reasonably available within 100 miles of my home.*
  • I certify that the cost of traveling to receive my cancer care creates a meaningful financial burden for me or my household, consistent with Bridge the Distance Fund's Financial Need Guide.*
  • I certify that I currently reside in Tennessee, Arkansas, or Mississippi.*
  • I certify that I am requesting assistance for upcoming travel related to my cancer care, not for travel that has already occurred. I understand that Bridge the Distance Fund does not reimburse for past travel or travel that has already been purchased*
  • I certify that the assistance I am requesting is for eligible travel and/or lodging expenses related to my cancer care. I understand that Bridge the Distance Fund assistance is limited to eligible travel and lodging expenses and does not cover meals, caregiver travel, or other expenses outside of the program's Travel Assistance Guidelines.*

  • By clicking SUBMIT you

    • Confirm the information you have provided is true to the best of your knowledge.
    • Authorize the care team member listed here to complete and submit the Care Team Certification Form for the purposes of this application.
    • Authorize Bridge the Distance Fund to use this information to review your request and arrange assistance, and to share it as needed with its fiscal sponsor, Social Good Fund, to process the grant.
    • Understand that assistance depends on available funds and is not guaranteed.
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