GUIDELINES FOR ASSISTANCE *

Guidelines for assistance: The Travis Burkhart Foundation strives to provide assistance to those facing a sudden or prolonged illness, injury or diagnosis. We provide support in the form of gas/food cards, money for hotel costs and medical expenses related to the undergoing medical treatment of an individual. *Assistance request must be filled out by someone other than the recipient, requester (person filling out the form) must be a medical professional, friend or close family member and must be living outside of the recipients household. *Assistance is not guaranteed and is dependent on available funds and board approval. *Assistance is limited to one time a month or 30 days. *The Travis Burkhart Foundation does not provide assistance for day to day living expenses. *When redeeming gas certificates the recipient must be present, in some cases ID may be required. * TBF is not responsible for replacing lost or stolen assistance cards/certificates. *Assistance given must be honored responsibly and used for the sole purpose that is intended. *Any misuse of assistance could adversely affect future assistance. *Requests for an iPad/DME require a LOR (Letter of Recommendation) from a medical professional. *Assistance could be affected if there is an active Go Fund Me account. *Must be a legal citizen in the United States,

I have read and understand the guidelines for assistance.

I am a legal citizen in the United States (requester)

The recipient is a legal citizen in the United States

Request for Assistance* *

****If you are requesting assistance and are not a resident of Indiana you may be required to submit a Letter of Recommendation (LOR) from a medical provider on their letterhead. It must include the individuals name that assistance is being requested for. Providing the Letter of Recommendation (LOR) along with the application will allow TBF to review your request in a more timely manner. Letter of Recommendation (LOR) can be emailed to travisburkhartfoundation@gmail.com. Or you may mail to TBF 10274 N 200 E Plainville, IN 47568. *Letter of Recommendation is a letter written by a medical professional who can recommend an individual's need for assistance.

I am NOT a resident of Indiana, I am sending a Letter of Recommendation by mail

I am NOT a resident of Indiana, I am sending a Letter of Recommendation by email

I am NOT a resident of Indiana, I am willing to send a Letter of Recommendation if needed

I am a resident of Indiana

Request for iPad/DME *

****If you are submitting a request for an iPad/DME you will need to send in a Letter of Recommendation (LOR) from either the primary care doctor, teacher or therapist. It will need to be on their business letterhead and must include the individuals name that the iPad is being requested for. Please send the Letter of Recommendation (LOR) to travisburkhartfoundation@gmail.com or mail to TBF 10274 N 200 E Plainville, IN 47568. *Letter of Recommendation (LOR) is a letter written by a medical/educational professional who can recommend an individual's need for assistance.

I am sending Letter of Recommendation by mail

I am sending Letter of Recommendation by email

I am NOT requesting an iPad/DME

Recipient Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Other Phone

(###)

###

####

Does recipient have insurance? *

Medicaid

Medicare

Other

No

Unknown

Hospital where care is being given *

Daviess Community Hospital (Washington)

Good Samaritan Hospital (Vincennes)

Jasper Memorial Hospital

IU Health (Bloomington)

Deaconess (Evansville)

Riley Children's Hospital (Indianapolis)

St Vincent Hospital (Indianapolis)

Terre Haute Regional Hospital

IU Methodist Hospital (Indianapolis)

St Vincent Hospital (Evansville)

Peyton Manning Children's Hosptial (Indianapolis)

Greene County General Hospital

Other

Distance per round trip for medical treatment *

Check the distance closest to what you travel.

20 miles

30 miles

40 miles

50 miles

60 miles

70 miles

80 miles

90 miles

100 miles

over 100 miles

over 150 miles

over 200 miles

Mode of transportation *

Car

Airplane

SAFS (Senior & Family Services)

Ride Solutions

Other

If you are requesting gasoline for transportation to medical appointments please check the preferred station. *

Casey's

Hucks

Jones Oil (Montgomery / Loogootee IN)

Cantwell's Short Stop (Vincennes IN)

N/A

Requester Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Other Phone

(###)

###

####

Relationship to Recipient (person needing assistance) *

Aunt

Brother

Brother in law

Client

Cousin

Coworker

Daughter

Daughter in law

Father

Father in law

Friend

Granddaughter

Grandfather

Grandmother

Grandson

Husband

Mother

Mother in law

Neice

Nephew

Patient

Sister

Sister in law

Son

Student

Uncle

Wife

Is recipient a minor? (under 18 years of age) If recipeint is a minor, please provide the information of the parent / guardian below. *

Yes

No

Parent / Guardian Name

First Name

Last Name

Parent / Guardian Phone Number

(###)

###

####