CURE SYNGAP1 | ProMMiS Travel Reimbursement Submission

Purpose:
CURE SYNGAP1 is committed to ensuring that participation in the ProMMiS study is accessible to all families, regardless of financial barriers. Please use this form to submit your expenses for reimbursement.

View the full travel reimbursement policy here.

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Email *
CONTACT INFORMATION
Full Name of Primary Caregiver: *
Full Mailing Address for check (Street, City, State, Zip) *
Country *
Phone Number *
Individual with SYNGAP1's full name *
APPOINTMENT DETAILS
ProMMiS Clinic Site Location (select one) *
Date of Visit *
MM
/
DD
/
YYYY
Travel Type *
Reimbursement Request
As a reminder, these are the 3 tiers you can be reimbursed for:
  1. For families flying (including international families): Flights, lodging for up to two nights, parking, and rental car or ride-share services (e.g., Uber, Lyft) expenses. These expenses can be reimbursed up to $1,000.
  2. For families driving or taking the train living within 6 hours of their NHS site: Gas or train tickets, parking, tolls, and lodging expenses for up to two nights. These expenses can be reimbursed up to $500.
  3. For families driving or taking the train living more than 6 hours from their NHS site: Gas or train tickets, parking, tolls, and lodging expenses for up to two nights. These expenses can be reimbursed up to $1,000.
*Coverage is for transportation and lodging only; please note food & beverages are not included.
Please create an itemized list of the expenses you are requesting reimbursement for. For example:

Airfare: $____
Train fare: $____
Gas: $____
Rental car: $____
Rideshare costs: (e.g., Uber, Lyft) $____
Tolls: $____
Lodging expenses: $____

*Please note: You must provide screenshots or copies of all receipts. 
 *
File Upload

Please upload screenshots or copies of your receipts and a screenshot of your RARE-X survey completion here: https://cureSYNGAP1.org/receipts 
Total Amount Requested (in USD) *
Confirmation
By submitting this form, I confirm that (check all): 
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Required
Thank you for filling out the form. You will receive a response from CURE SYNGAP1 within 10 business days. 
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