CURE SYNGAP1 | ProMMiS Travel Support Application

Purpose:
CURE SYNGAP1 is committed to ensuring that participation in the ProMMiS study is accessible to all families, regardless of financial barriers. We have limited funds available to help offset travel-related costs for families who truly need financial support to attend their clinic visit. Please use this form to request assistance.

Note: We do not ask for proof of income or personal financial information. This program operates on the honor system. We trust our community to apply only if support is genuinely needed.

View the full travel reimbursement policy here. 

Sign in to Google to save your progress. Learn more
Email *
CONTACT INFORMATION
Full Name of Primary Caregiver: *
Complete Mailing Address (including city and state if applicable) *
Country *
Phone Number *
Individual with SYNGAP1's full name *
APPOINTMENT DETAILS
ProMMiS Clinic Site Location (select one) *
Date of Scheduled Visit *
MM
/
DD
/
YYYY
Travel Type *
Distance - Do you live more or less than a 6-hour drive from your ProMMiS site? *
Required
Estimated Number of Travelers (including patient): *
Travel Support Justification

Please let us know how this travel support will impact your ability to join the study. 

 *
Confirmation
By submitting this form, I confirm that (check all): 
 *
Required
Thank you for filling out the form. You will receive a response from CURE SYNGAP1 within 7 business days. 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of CURE SYNGAP1.

Does this form look suspicious? Report

Google Forms