Personal Background

OMF TAG travel grants are entirely need-based and disbursed at the sole discretion of OMF. Typically, individuals who earn, as a household, less than $100K annually will be considered though OMF prioritizes acute cases of financial need such as household income below $40,000 per year and/or instances where the patient has suffered financial hardship (for instance, lost their job) as a direct result of their eye cancer diagnosis). However, every case is different and we will do our best to assist you and reduce the financial burden of your treatment-related travel. 

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* 1. Contact Information

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* 2. What is your gender?

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* 3. Birthdate (DD/MM/YYYY)

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* 4. Marital status:

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* 5. How many dependent children do you have? (must be shown on tax return)

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* 6. Have you applied to the OMF TAG Program before?

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* 7. If travel is being requested for a caregiver companion, please enter their
information here (name/address/relationship/etc.)

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