PLEASE NOTE:
An applicant is responsible for getting to and from an airport, bus station, or train station. We do not provide money or reimbursement for that portion of a trip. Applicants are also responsible for any baggage fees assessed by an airline.

Client Information


If reason for travel is due to a funeral, please provide funeral home contact information here (name of deceased, relationship to deceased, name of funeral home, and funeral home phone number)

IF YOU WILL BE THE TRAVELING PARTY, COMPLETE THE FOLLOWING:

In order to make complete travel arrangements, we request the following information.

IF YOU WOULD LIKE TO BRING FAMILY/FRIEND(S) HERE, COMPLETE THE FOLLOWING:




Indemnification and Release. Applicant hereby releases and forever discharges Home for the Holidays Texas, Inc., its Board of Directors, its Committee members, and its volunteers, sponsors, and agents from any and all liabilities, claims, demands, and actions for personal injury, death, and personal property, including, but not limited to losses arising or in any way from the applicant's travel facilitated by a Home for the Holidays Texas, Inc. travel grant in connection with this application.


To be completed by the case manager or agency representative.
It is imperative that the agency accurately assesses the urgency of the beneficiary's need to travel. We rely on your help for this so PLEASE give this careful consideration. Please refer to the criteria and information packet for guidance and circle the number that best represents your client.
If not, please respond to the following
Please indicate whether you believe the applicant's health makes his/her need to travel urgent, or assess the need to bring a caregiver to help the client's needs. Based on the client care recognized Karnofosky Scale (attached in this packet), please select the appropriate health status, understanding that the lower number represents the most critical health status.
Please indicate the benefit, either physical or psychological, that the applicant would derive from traveling home, or bringing family or friends to the metroplex, with 10 indicating greatest benefit and 100 indicating least benefit .