Travel Assistance Grant with Eye on Grace Foundation

Confidential Questionnaire

The Eye on Grace travel grants are available only for people diagnosed with Ocular/Uveal Melanoma who must travel more than 25 miles for treatment. Eligible individuals are required to provide proof of diagnosis and proof of treatment-related travel. Grants awarded will be up to $1,000 per person per treatment and may cover expenses for the patient and one caregiver. This includes lodging, travel, Uber/Lyft, and food gift cards. Grants may be granted up to 10 times per patient per year with a maximum lifetime award of $25,000. We understand every case is different and we will consider every request and strive to reduce the financial burden of treatment-related travel.

Question Title

* 1. Personal Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. What is your date of birth?

Question Title

* 3. Describe your diagnosis.

Question Title

* 4. Can you provide documentation of diagnosis (I.e. doctor's note signed by a Certified Doctor, Castle Diagnostic Report, MRI/CT/Ultrasound report).

Yes

Question Title

* 5. What type of treatment will you be having?

Question Title

* 6. Where will treatment be delivered? (Name of facility, city and state.)

Question Title

* 7. You will need to provide a Plan of Care from a certified physician. Will you be able to provide this?

Yes

Question Title

* 8. If travel is being requested for a caregiver/companion, please provide the following information: Name, address, email, phone number, and relationship to the patient.

Question Title

* 9. Is the location for treatment more than 25 miles from where you live?

Question Title

* 10. Have you applied for an Eye on Grace Foundation Grant before? If so how many times in a calendar year? (Note: A person can only receive 10 grants a year with a lifetime maximum of $25,000.)