This form is to be completed by families that have been approved for financial travel support and who have signed a formal contract. A member of our team has provided a Destination ID for your family. Please use that unique ID to complete the form below. If you have any difficulties, or need further assistance, please contact our office at (563) 231-0458.
As a reminder, requests must be received at least 2 days prior to departure to ensure payment.
If your family has not been approved for assistance, but needs help getting your child to treatment, please click here to learn more about applying.