"We strive to bring hope and support to those facing a sudden or

prolonged injury, illness or diagnosis"

PLEASE READ CAREFULLY!

In need of assistance? Guidelines for assistance: The Travis Burkhart Foundation strives to provide assistance to those facing a sudden or prolonged iNJURY, ILLNESS 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 once every 30 days.

*The Travis Burkhart Foundation does not provide assistance for day to day living expenses. 

If a loved one or someone you know meets the guidelines for assistance please fill out the below form.  **Requests may not be filled out by the person needing the assistance. The request must be filled out by a medical professional, friend or close family member outside of the home.  Although the Travis Burkhart Foundation will try to answer the request as soon as possible, response rates will vary depending on volume of pending requests.

 By submitting the below form you are giving the Travis Burkhart Foundation consent and authorization to share all information to the board. The information provided will not be shared outside of the Travis Burkhart Foundation and will not be used in any way other than to determine level of assistance needed.  

****If you are submitting a request for an iPad you will also need to send in a Letter of Recommendation from either the primary care doctor, teacher or therapist. It will need to be on their business letter head and must include the individuals name that the iPad is being requested for. Please send the Letter of Recommendation to TBF 10274 N 200 E Plainville IN 47568. 

GUIDELINES FOR ASSISTANCE *
Guidelines for assistance: The Travis Burkhart Foundation strives to provide assistance to those facing a sudden or prolonged injury, illness 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 is not guaranteed and is dependent on available funds and board approval. *Assistance is limited to one time a month or once every 30 days. *The Travis Burkhart Foundation does not provide assistance for day to day living expenses.
Recipient Information (person recieving assistance)
Name *
Name
Address *
Address
Cell Phone *
Cell Phone
Other Phone
Other Phone
It is important to inform us of the number or trips you make per month or every 30 days to your medical treatments. By doing this we are better informed and can help you in a more efficient and effective way.
Distance per round trip for medical treatment *
Check the distance closest to what you travel.
Mode of transportation *
Point of Contact/Requester Information (person filling out form, must be someone not living in the same household)
Name *
Name
Address *
Address
Cell Phone *
Cell Phone
Other Phone
Other Phone

**Submitting this form does not guarantee that assistance will be given due to the availability of funds at the time of request.** 

Please complete the above form and submit. There is also a possibility of more information needed to approve request,

if this is needed you will be contacted.

**Please allow a minimum of 7 days for response or assistance to be granted.**