Please explain the details about your travel (# of travelers, days traveling, mode of transport, distance from home to specialist).
Please list the details of the specialist you are traveling to see (name, practice info, specialty) as well as the reason why you have chosen or been referred to this specialist.
Application Certification *
I certify that the information presented in my application is accurate and complete. I understand and agree that any inaccurate information, misleading information, or omission will be cause for the invalidation of any grant offered to me. NF Michigan may verify any, and all parts of my application materials. NF Michigan will only use application information for purposes of rewarding grants and will hold all information private.