Jeune’s Syndrome Family Foundation
Melissa Benson, Director
P.O. Box 261181, Highlands Ranch, CO 80163
Application for Travel Assistance
Today’s Date:
Name of Parent/Guardian:
SSN of Parent/Guardian:
Address:
Address:
Phone:
Alternate Phone:
Email:
Name of Child:
Age of Child:
Diagnosis:
Procedure:	Evaluation / Implant / Expansion / Exchange / Other:
Date Scheduled:
Hospital:
Contact Person:
**Please include a Release of Medical Information form for the facility you will use so that we may verify information with the contact person.
**Please attach a brief statement about your child and family. Include ways that your child’s experiences have affected your family, positively or negatively. Also, please attach a photograph of you child.
Check all that apply:		__ We would like to be involved in a parent Network. Please send an information packet.
		__ Please add us to your mailing list for newsletters.
		__ We would be interested in attending JSFF activities.
*Quarterly application deadline. Applications postmarked by January 1, April 1, July 1 or October 1 will be considered for funds distribution in the following quarter. Amount of assistance will range between $300-$1000, depending on expected length of hospital stay and funds availability.
*Unless you specify otherwise, your family’s story and/or the likeness of your child may be used on the Jeune’s Syndrome Family Foundation web site or in its marketing material. Personal information such as full name, address and SSN will never be distributed to any other organization or party, except as required by law.
Return this form to:		Melissa Benson, Director
		Jeune's Syndrome Family Foundation
		P.O. Box 631181
		Highlands Ranch, CO 80163-1181