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Hops from Hailey Application
  1. Our Hops from Hailey program provides $100 gas gift cards to eligible families seeking treatment beyond the Standard of Care radiation therapy for their child diagnosed with DIPG/DMG. The gas card is intended to help offset some of the cost of travel to/from a treatment center or hospital.

To be eligible: 
1. Child must have been diagnosed with either Diffuse Intrinsic Pontine Glioma (DIPG) or Diffuse Midline Glioma (DMG)
2. Child must reside in the United States.
3. Child must be 21 years old or younger.
4. Child must be in active treatment or seeking treatment beyond the standard of care radiation therapy for DIPG/DMG. For the purposes of this program, active treatment includes being evaluated for a clinical trial at a hospital/treatment center in the U.S., being enrolled and receiving treatment on a clinic trial, receiving re-irradiation therapy at disease progression, or being actively treated as part of an expanded access or compassionate use drug therapy program that requires regular monitoring at a treatment center/hospital in the United States.
5. Patient family must reside 50 miles (round trip) away from the hospital/treatment center. 
6. You must also certify that you will not receive reimbursement from the clinical trial or hospital for this travel.

This is a grant-funded program by IronMountain Solutions, Inc. and gift cards will be dispersed until grant funds are depleted.

Questions? Please contact DeeDee at princesshaileyshope@gmail.com. We would love to help!

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Email *
Patient/Family Information
Patient's Name *
Patient's Date of Birth (Must be 21 years old or younger to qualify) *
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Patient's Sex *
Name of Parent/Guardian(s)  *
Patient's Address (We will confirm the mailing address for your gift card once we receive your application.) *
Telephone Number *
Diagnosis and Treatment Information
Patient's Diagnosis (Please select one) *
Patient's Diagnosis Date *
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Name of Oncologist *
Name of Hospital/Treating Facility *
Please select the type of treatment that the patient will receive at this hospital or center. *
Social Worker or Case Manager's Name *
Social Worker's Phone Number *
Social Worker's E-mail Address *
Additional Demographic Information
If you feel comfortable, please provide your race. This information is only collected to show the diverse population that DIPG/DMG impacts for grant reporting. Check all that apply. *
Required
Gift Card Preference
Please select preferred gift card.  *
Certification and Submission
Please certify the statements below. Upon submission, our Hops from Hailey coordinator will be in touch via e-mail to coordinate delivery of your gas gift card.
By submitting this form, I certify that we reside 75 miles or more away from our clinical trial or treating center and that we are not being reimbursed by a clinical trial or hospital for this travel. *
By submitting this form, I also consent for Princess Hailey's Hope Foundation to contact my social worker to verify that my child is a DIPG/DMG patient receiving the treatment outlined in this application form. *
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