Travel Form | Jake's Help From Heaven

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

Section A: Personal Information

Applicant(Required)

First Last

Parent/Guardian (if applicable)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Age(Required)

Please enter a number from 1 to 150.

Email(Required)

Daytime Phone #(Required)

Evening Phone #(Required)

Describe your medical condition and the treatment you are seeking. Include why it is necessary to travel 90 miles or more to seek treatment/services as well as where you will be treated and by whom.(Required)

Section B: Medical Treatment/Services Information

Doctor and Facility(Required)

Facility Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Section C: Travel Information

Please fill out the Expense Worksheet COMPLETELY. This includes totaling all appropriate columns. You may upload your documents here or mail your documents in.

Travel Expense Worksheet

Expense Worksheet(Required)

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.

Post appointment letter/discharge notes(Required)

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

Section E: 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 to enable travel for medical treatment/services. I understand that I may be required to provide additional evidence of submitted information and I give permission to Jake’s Help From Heaven to contact the medical facility for verification purposes. I agree to allow Jake’s Help From Heaven to use my name in announcements and related publications.

Signature of Applicant or Parent/Guardian:(Required)

Printed name of Applicant or Parent/Guardian(Required)

First Last

Date(Required)

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.

Signature of social worker or primary doctor

I support (applicants name) application for (requested item) on (date)”

Printed name of social worker or primary doctor(Required)

First Last

Contact phone number or email for the doctor/social worker(Required)

Date