Living Rare, Living Stronger Travel and/or Lodging Assistance Application

Click here to download the application FAQs.

Applicant Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Please describe yourself.(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is your connection to the rare disease community?(Required)

Disease of Interest(Required)

In what ways will attending this conference benefit you?(Required)

Location(Required)

Please select the most important benefit to you.(Required)

Please select the two most important benefits to you.(Required)

1 night stay at the hotel

2 night stay at in the hotel

Complimentary flight provided through Patient Airlift Services (PALS) (Applicants must live a considerable distance from Cleveland.)

Complementary Flight Application

NORD Member Organization, PALS (Patient Airlift Services) is able to help provide flights to and from the Living Rare Forum in Cleveland, Ohio. PALS provides free medical and compassion flights for patients and veterans. Volunteer pilots use their own personal aircraft to provide the flight. If you are interested in learning more about PALS before requesting this portion of the travel and lodging application, please visit https://palservices.org/free-air-transportation-services-patients/medical-flight-cost-faq

I am(Required)

Departure Date(Required)

Return Date(Required)

Must coincide with conference agenda; vacation time cannot be accommodated

Primary Patient Name(Required)

Number of Additional Passengers(Required)

Your Home City(Required)

Your Home State(Required)

Zip Code(Required)

Nearest Major, International Airport(Required)

Nearest Small, Regional Airport(Required)

Please list illness/disability or reason for attending(Required)

Description of illness / Notes(Required)

Required Equipment / special needs(Required)

(i.e. portable oxygen, auto-immune, car seat for infant, wheel chair)

If wheelchair what type, weight & dimensions?

i.e. motorized, collapsible, dual function

Primary Passenger Weight(Required)

Primary Passenger Height(Required)

Primary Passenger Date of Birth(Required)

Does this passenger have a history of seizures?(Required)

If yes, please state type of seizures and date of last seizure.(Required)

Companion Information

Up to 3 companions

Name

Height / Weight

Date of Birth

Does Companion 1 have a history of seizures (Yes / No?)

If yes, please state type of seizures and date of last seizure.