Application for Travel Support


Application for Travel Support

Please fill in all the blocks below COMPLETELY for your application for a grant that will help cover the travel expenses it costs for you to visit your wounded service member.  We highly recommend that the next of kin of the listed Soldier fill this application out. Thank you!

Rank and Full Name of Injured Soldier:
Gender:  
Home of Record:
Current Duty Station:
Unit Deployed With:
Location of Deployment:
Injury Received on Deployment:
Reason for Requested Travel (i.e. injured Soldier is having surgery or rehab, etc.):
Start Travel Dates:
End Travel Dates:
Departure Airport (City, State):
Arrival Airport (City, State):
Estimate of Requested Funds:  
Name of Passengers (list up to 3). Include Age, Gender, and Relation to Injured Soldier:
Birth Dates of all Passengers:
Contact Information of Requester (Phone # and Email):
Name and Contact Information (Phone # and Email) of Supervisor or Commanding Officer :  
Medical Facility Where Soldier is Being Treated:
Name and Contact Information (Phone # and Email) of Doctor/Medical Personnel::
Comments:

Please note the following:
(1) We reserve the right to approve the number of travelers to receive assistance.
(2) Airline tickets will be issued electronically through email.
(3) Priority for travel is given to family members in the following order: spouse, children, parents, siblings.
(4) Contact Fisher House for housing assistance.