Application Packet

General Requirements For SMOV Application

  • Applicant must be diagnosed with breast cancer and have undergone treatment.
  • Applicant must demonstrate that she has endured economic disadvantage.
  • The Application must be made by the Applicant, not a friend or family member.
  • The Applicant must acknowledge that the Vacation will be safe and not be contraindicated by her medical providers.
  • Applicant must submit a personal story describing why she believes her circumstances warrant the Survivors Committee for Send Me On Vacation, Inc. granting a Vacation to her.
  • Applicant must complete, sign and send the SMOV Application Form, Contact Information, SMOV Vacation Preferences, and SMOV Agreement to Send Me On Vacation, Inc.
  • Applicant must complete, sign and send the HIPPA (Health Insurance Portability and Accountability Act) form.
  • Applicant’s physician must fill out and return to Send Me On Vacation, Inc. the Medical Statement and Consent to Participate.
  • Please send three current original photographs of the Applicant via email in .jpeg or other high-resolution format. Please do not fax or mail photos.

 

Download Send Me On Vacation Application Packet