Thank you for reaching out to Fill the Gaps in Lung Cancer. This combined form serves as both your Travel Assistance Application and your Prepaid Travel Card Agreement. Please complete all sections thoroughly. If you need help completing this form, do not hesitate to contact us — we are here to support you.
Part 1 — Travel Assistance Application
Section 1: Patient Information
Section 2: Financial Need Statement
Fill the Gaps in Lung Cancer provides travel assistance to patients who demonstrate financial need. Please check each box to affirm the following:
Section 3: Clinical Trial Information
Section 4: Travel Expense Calculator
Enter your estimated unit costs and quantities below. Totals calculate automatically.
Expense
Unit Cost ($)
Quantity / Days
Unit
Total Cost
AirfareCoach/economy only; book early
trips
$550.00
Hotel / LodgingAsk about partner hotel rates
nights
$1,275.00
Food Per DiemOrganization standard: $92.00/day
days
$460.00
Parking
days
$12.00
Taxi / Uber / Lyft
trips
$68.00
Mileage Reimbursement$0.21/mile · 2026 IRS Medical Rate
miles
$126.00
Total Estimated Request
$2,491.00
Note: These are estimates only. Actual reimbursements are subject to receipt submission and approval under the terms of the Prepaid Travel Card Agreement below.
Section 5: Caregiver Information
Note: One designated caregiver is eligible for the same travel assistance categories and rates as the patient. Caregiver expenses should be included in the estimated totals above.
Section 6: How Did You Hear About Us?
Part 2 — Prepaid Travel Card Agreement
A Note on Stewardship
The funds on your prepaid travel card come directly from generous donors who believe no lung cancer patient should face financial barriers to clinical trial participation. We ask that you treat these funds as you would your own money — book early, choose cost-effective options, and spend thoughtfully. Responsible use ensures that Fill the Gaps in Lung Cancer can continue to support other patients and caregivers in need. Thank you for being a partner in this mission.
1. Purpose and Scope
1.1 Fill the Gaps in Lung Cancer ("the Organization") is a nonprofit organization that provides prepaid travel cards to eligible lung cancer patients for the purpose of reducing financial barriers to clinical trial participation.
1.2 Funds loaded onto the prepaid travel card are restricted exclusively to expenses directly related to travel for clinical trial participation and must be used solely in accordance with the terms of this Agreement.
1.3 The patient receiving the prepaid travel card ("Recipient") agrees to use all funds solely in accordance with the terms of this Agreement and acknowledges that any deviation may result in the consequences described herein.
2. Eligible Expenses
2.1 The prepaid travel card may be used only for the following expense categories. All expenses must be directly related to the Recipient's participation in an approved clinical trial.
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Expense Category
Description and Limits
1
Airfare
Round-trip or one-way flights; coach (economy) class only. Book as early as possible.
2
Hotel / Lodging
Accommodations at or near the trial site. Reasonable and cost-effective; inquire about partner hotel rates. Luxury or resort stays are not eligible.
3
Ground Transportation
Taxi, Uber, Lyft, or rideshare to/from airports, hotels, and trial sites. Rental cars require prior written approval.
4
Mileage Reimbursement
Personal vehicle use at $0.21 per mile (documented round-trip mileage). Tolls and parking fees directly related to trial visits are also eligible.
5
Food Per Diem
Daily food allowance of $92.00 per day for days of active travel or treatment at the clinical trial site.
2.2Ineligible Expenses: The prepaid card may not be used for personal purchases, entertainment, alcohol, tobacco, gift cards, cash advances, or any non-trial-related expenses.
3. Caregiver Inclusion
3.1 Eligible expenses extend to one (1) designated caregiver accompanying the Recipient. The caregiver identified in Section 5 of this document is the designated caregiver for this Agreement.
3.2 Only one (1) caregiver may be designated at a time. Changes must be submitted to the Organization in writing prior to travel.
3.3 Caregiver-eligible expenses include:
Airfare to and from the clinical trial site;
Hotel and lodging at or near the clinical trial site;
Ground transportation to/from airports, hotels, and the trial site; and
Food per diem of $92.00 per day for days of active travel or treatment.
4. Expense Reporting and Receipt Submission
4.1 Receipts and a completed Expense Report must be submitted to the Organization by the 5th of each month for the preceding month's expenses.
4.2 Each Expense Report must include: (a) date of expense; (b) expense category; (c) amount; and (d) purpose (e.g., "Uber to UCLA Medical Center for Day 1 Cycle 3").
4.3 All receipts must be legible and itemized. Credit card statements alone are not sufficient documentation.
4.4 Mileage reimbursement requires a mileage log showing date, origin, destination, and total round-trip miles driven.
4.5 Failure to submit receipts by the deadline may result in suspension of card funding until compliance is restored.
5. Return of Unused Funds
5.1 Upon completion, withdrawal, or termination of the clinical trial, the Recipient must return all unused funds within thirty (30) days.
5.2 The Organization will provide written instructions for returning unused funds.
5.3 Failure to return unused funds may result in ineligibility for future assistance from the Organization.
6. Misuse of Funds
6.1 Any use of funds for purposes not described in Section 2 constitutes misuse.
6.2 In the event of misuse, the Organization may: (a) immediately deactivate the prepaid card; (b) require full reimbursement; and (c) permanently disqualify the Recipient from future assistance.
6.3 The Organization will provide written notice and allow the Recipient an opportunity to respond before a final determination is made.
7. Confidentiality and Data Privacy
7.1 All personal and clinical trial information will be held in strict confidence and used solely for administering the Travel Assistance Program. Information will not be disclosed to third parties without prior written consent, except as required by law. All records will be stored securely and destroyed after the retention period required for financial reporting and compliance.
8. Funding Availability
8.1 The Travel Assistance Program is funded entirely through charitable donations. The Organization cannot guarantee future fund availability. Approval of this Agreement does not constitute a guarantee of funding for the entire duration of clinical trial participation.
9. Acknowledgment and Signatures
By submitting this form, I certify that the information provided is true, accurate, and complete. I have read, understand, and agree to comply with all terms and conditions of this Patient Prepaid Travel Card Agreement. I understand that funds are exclusively for clinical trial travel-related expenses and I accept responsibility for proper use, documentation, and return of funds. I acknowledge that misuse or failure to comply with reporting requirements may result in suspension or termination of travel assistance.
I further understand that funding is based entirely on charitable donations and is subject to availability; approval does not constitute a guarantee of funding for the entire duration of clinical trial participation.
Patient (Recipient)
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Designated Caregiver
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✅ Application submitted successfully! A member of the Fill the Gaps in Lung Cancer team will be in touch shortly. If you need immediate assistance, email thomas@fillthegapsinlungcancer.com.