Jake’s Help From Heaven Medical Travel Application

Jake’s Help from Heaven, founded in 2011, is a non-profit dedicated to supporting individuals with complex medical needs and disabilities resulting from congenital or childhood-onset diseases. Our primary objective is to improve the livelihoods of these persons as they confront the challenges of managing lifelong, debilitating illness.

Please read the following requirements carefully. Incomplete applications or those submitted in unacceptable formats will not be reviewed.

Grant Eligibility:

  • Grants are limited to individuals living within 100 miles of Saratoga Springs, New York.
  • Grants are restricted to individuals with complex medical needs and disabilities resulting from congenital or childhood-onset diseases. Applicants of all ages with lifelong, debilitating illnesses are welcome to apply.

Grant Criteria:

  • A post-appointment letter or complete discharge notes from the treating doctor indicating reason(s) for treatment and the treatment dates are REQUIRED.
  • Completed Expense Worksheet with all columns totaled. Applications will not be reviewed if the worksheet is not completed.
  • Completion of the following application with the signature of pediatrician/primary care doctor or social worker.
  • Receipts for reimbursement
  • Applicants should submit their completed applications with all required documents at one time, and not in separate pieces.
  • Electronic applications must be submitted in PDF format. We DO NOT accept jpegs or screenshots.
  • There is a $2,500 cap per applicant per calendar year. Applicants may apply multiple times within a calendar year but are only eligible to be awarded a total of $2,500 within that year.
  • Applicants requesting a grant of over $1,000 may be asked to submit a current income tax return or other financial information.
  • Grants will be reviewed four times per year at the Board of Directors’ quarterly meetings. Approved grants will be awarded approximately 3 weeks after each meeting.  Application deadlines and meeting dates can be found on Jakeshelpfromheaven.org.

Jake’s Help From Heaven Medical Travel Application 2024

Section A: Personal Information

Applicant(Required)
Please enter a number from 1 to 150.
Parent/Guardian (if applicable)
Address(Required)

Section B: Medical Treatment/Travel Information

Please fill out the attached Expense Worksheet COMPLETELY. This includes totaling all appropriate columns. Applications will not be reviewed if this sheet is not filled out.

Facility Address(Required)

Completed expense worksheet is REQUIRED. You may upload your documents here or mail your documents in.

Download the Expense Worksheet as an EXCEL file or PDF
Accepted file types: jpg, pdf, Max. file size: 2 MB.

A post appointment letter or complete discharge notes from the treating doctor indicating reason(s) for treatment and treatment dates is REQUIRED. You may upload your documents here or mail your documents in.

Accepted file types: jpg, pdf, Max. file size: 2 MB.

Receipts for reimbursement are REQUIRED. You may upload your documents here or mail your documents in.

Drop files here or
Accepted file types: jpg, pdf, Max. file size: 2 MB.

    Section C: Disclosure/Signature

    I declare that the information provided on this application for financial assistance is true and complete to the best of my knowledge. I understand that what I submit to Jake’s Help from Heaven is for the purpose of financial reimbursement or direct purchase of medically necessary or convenient items and services. I understand that I may be required to provide additional evidence of submitted information, including a current income tax return or other financial information. I give permission to Jake’s Help from Heaven to contact the provided medical facility for verification purposes. I agree to allow Jake’s Help from Heaven to use my name in announcements and related publications.
    Printed name of Applicant or Parent/Guardian(Required)
    MM slash DD slash YYYY

    You may upload a photo or a scan of a signed document from your doctor with the endorsement saying "I (social worker or primary doctor) support (applicants name) application for (requested item) on (date)” or use the save and continue option and send your social worker or primary doctor the link for them to sign. After adding their signature, your doctor or social worker must then use the save and continue option and send you the new link to your form.

    I support (applicants name) application for (requested item) on (date)”
    Accepted file types: jpg, pdf, Max. file size: 2 MB.
    Printed name of social worker or primary doctor(Required)
    MM slash DD slash YYYY