Our mission is to provide brief respite trips for cancer survivors and their caregiver. You may submit this form for yourself or on behalf of a survivor. Trips are awarded and organized based on availability; we cannot guarantee a specific trip location when you apply.

Qualified candidates:

* must have physician diagnosis of cancer.

* must be in active treatment or less than 12 months out from treatment/24 months from treatment for bone marrow transplant patients. Active treatment is chemotherapy, radiation, and/or surgery.

* must not have traveled on a self-funded trip or a trip through another nonprofit.

* Arkansas residents are given first priority, but patients outside of this area will be considered.

* there is no income limit, but we want to help those in the greatest need who are unable to fulfill a brief trip on their own.

Trips are decided by our advisory committee based on availability.

Name *
Name
Phone *
Phone
Date *
Date
Date of Diagnosis
Social Worker or Oncologist Name *
Social Worker or Oncologist Name
Survivor is able to travel to the location on the specified date *
Check all that appply
Name
Name
Your name if submitting on behalf of a survivor
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