Hermanowski Family Foundation Initial Request Form

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Organization Name: CHARGE Syndrome Foundation
Legal Name (if Different):
Also Known As:
Mailing Address: 318 Half Day Rd. #305
City: Buffalo Grove
State: IL
Postal Code: 60089
Main Phone: 210-842-8987
Main Fax:
Organization Website: https://www.chargesyndrome.org
Employer ID Number: 43-1642150
Organization Tax Status: 501c3

Proposal Information

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Today’s Date: 01/24/2023
Requested Amount: 10,000

Project Title: Family Assistance Program – Medical Travel
Project Description:

Because of the significant medical complexities that are present with CHARGE syndrome, families are often forced to travel long distances for specialized medical and therapeutic care for their child. This funding will be used to cover transportation, meals, lodging, and parking for medical care that requires out of state/long distance travel. The program is intended for families who would benefit from assistance to cover the cost for travel to receive medical care for their family member with CHARGE syndrome.
This program benefits individuals with CHARGE syndrome and their families or caregivers, particularly families with household incomes below $50,000 annually. Since its inception, the Foundation has supported over 400 families across the United States with costs associated with their necessary medical travel. In response to rising costs of travel, the program is being expanded to increase average award amounts from $620 per request to $720 per request. The Foundation hopes to assist at least 14 families with this award.

Award Requirements:
• A family member must have a diagnosis of CHARGE syndrome
• Applicant must live and receive medical care in the United States
• Eligible Travel must be over 100 miles roundtrip
Reimbursable Expenses:
• Transportation, including gas, airfare or train fare
• Meals during travel
• Lodging
• Parking

If a family has an unplanned medical trip, which can be common with a complex and medically severe condition like CHARGE syndrome, they can request reimbursement within 30 days after returning home from a completed treatment.

This program is evaluated on an annual basis, and reports are disseminated quarterly. Key performance indicators for 2023 include: an increase in average award amounts by 16%, an increase in awards to households with a combined total household income of less than $50,000 and an improvement in physical and mental health of awarded individuals.

Total Project Budget: 50,000

Other Funding
Sources For The Project (Committed & Potential): Alcon Foundation, Centene Charitable Foundation, Sorenson Legacy Foundation, The Lawrence Foundation, Dr. Scholl Foundation, Menasha Corporation Foundation, Max and Victoria Dreyfus Foundation

Project Duration: 1 year
Geographical Area Served: nationwide
Age Group To Be Served: 0-21

Contact Information

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Contact Prefix (Mr,Mrs etc.): Mrs
Contact First Name: Lisa
Contact Last Name: Cunningham
Contact Title: Executive Director
Contact Phone: 210-842-8987
Contact Email: lisa@chargesyndrome.org