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Travel for Care Dental Stipend Program Application Form

Eligible Patient Information

First Name*

Last Name*

Date of Birth

Email Address*

Cell Phone

Address, line 1

City

State

Zip Code

Parent/Legal Guardian information (only required for individuals under the age of 18)

Parent/Guardian Name(s)

Travel: Treatment / Services Information

Doctor/Facility

Dental Procedure

Appointment Date(s) and Time(s)

Travel Start Date

Travel End Date

I would like to receive stipend assistance in the form of:

Reimbursement of expenses after travel I am asking the IFOPA to pay upfront travel and lodging costs

(Only for patients not traveling by personal car.) Please share any special travel accommodations you require.

Conditions of Acceptance

If awarded a travel stipend for dental care, you agree to the following conditions:

I understand that I may be required to provide evidence of submitted information and that the International FOP Association may contact the medical facility for verification purposes.

I understand that I will be notified by email as to the status of this application and have provided a valid email address.

(Only for families requesting the IFOPA pay the upfront travel and lodging cost) I understand that if I do not travel to Philadelphia for the above listed dental procedure I must reimburse the IFOPA for the stipend I received, unless the cancellation is due to a medical emergency. If you experience a medical emergency and are able to receive a full or partial refund from travel and/or lodging vendors, you must refund any amounts you receive to the IFOPA.

Submitted By

Submit

Date

ORGANIZATION NAME
ORG ADDRESS LINE 1 ORG ADDRESS LINE 2
ORG CITY, ORG STATE ORG ZIP
ORG CONTACT PHONE
ORG CONTACT EMAIL

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