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Travel Assistance Application
Name(Required)
Address(Required)
Your Employment Status(Required)
Eligibility Requirements (By Checking Each Box You Confirm you Meet all Requirements)(Required)
Names of People attending Retreat and Relationship
Person Attending Name
Add Another Person
Person Attending Name
Add Another Person
Person Attending Name
Add Another Person
Person Attending Name
Add Another Person
Person Attending Name
Add Another Person
Person Attending Name
Add Another Person
Person Attending Name
Add Another Person
Person Attending Name
If you are Divorced or File Separate, please list the name of the individual on which your taxes are filed on. You agree that your minor dependents who are not reflected on your taxes are included on another persons taxes and that your income/tax status is reflected for them.
Name of Person who claims my children as dependent(s):
Max. file size: 50 MB.
The only document that should be uploaded here is your Federal Tax form for the most recent year you have filed- Do NOT upload your W2!.
If you would like to provide additional information for consideration by our committee please include in the Additional Documents Upload Section:
Example of Additional Documentation. Your previous tax year you were working, but you have recently been put on disability decreasing your income for this year. Upload Previous W2 & Disability Benefit Documentation.
Drop files here or
Max. file size: 50 MB, Max. files: 4.

    Driving

    I am applying for:

    Flying

    I am applying for:

    Example #1:

    If you are the patient traveling with your spouse and 2 children, if eligible and approved, you would receive a travel stipend of $1,250 to be used on travel.

    ($500 for you and $250 x 3 household members = $1,250)

    After booking your tickets with our corporate travel partner, your total for your tickets comes to $900, leaving you a remaining credit of $250. This amount will be provided to you directly to help cover the cost of a rental vehicle as well as bag fees, travel incidentals, etc.

    Example #2:

    You have the same family configuration and are awarded the same amount for travel as example #1= $1,250. You book your travel arrangements, and the total cost is $1,300. The travel agency will credit your account $1,250 as per your award allotment and you would be responsible to pay for the remaining $50.

    Couples
    Agreement(Required)
    I understand that travel assistance funding is designated as restrictive use funding and as such, these funds should only be used solely to aid in my travel to and from the retreat location. All airline tickets will be made through Little Pink's corporate travel partner to receive funds. If I choose not to attend the retreat for any reason (medical, personal, crisis, family, death, etc.),  I understand that I am required to return my funding within 30 days of declining my acceptance. Funds that are returned will be used to help another family with their travel assistance needs.

    Little Pink Houses of Hope, its employees, and agents are hereby authorized to obtain and discuss medical, treatment, therapy, financial, and other information relating to the applicant with the applicant’s healthcare providers, employer, and/or any other person or entity working with Little Pink Houses of Hope on the applicant’s behalf for purposes of confirming the applicant’s eligibility for the Travel Assistance Program.

    Little Pink Houses of Hope may also use or disclose the applicant’s personal information as necessary to provide applicants with assistance under the program. Little Pink Houses of Hope may anonymize and deidentify applicant information and data and use such information for Little Pink Houses of Hope's own purposes, including developing aggregate reports. Neither Little Pink Houses of Hope nor any of its employees or agents will disclose any applicant identifiable information to any third party except as provided above, as required by law, or as deemed appropriate by Little Pink Houses of Hope to investigate or resolve any potential fraud or audit irregularity.
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