Our website includes a link detailing Frequently Asked Questions (FAQs) and responses thereto. Read our FAQs prior to completing this application. Those FAQs relative to patient qualifications, the application process, respites and financial information are incorporated herein by reference.

Name of Person Filling Out Application (Note: A Week Away is currently only accepting referrals from the patient, a parent/legal guardian of patient, and a physician/medical staff employee from which the patient is treating)
Name of Person Filling Out Application (Note: A Week Away is currently only accepting referrals from the patient, a parent/legal guardian of patient, and a physician/medical staff employee from which the patient is treating)
Phone Number
Phone Number
Patient's Name
Patient's Name
Patient's Address
Patient's Address
Patient's Phone Number
Patient's Phone Number
Date of Diagnosis
Date of Diagnosis
Will the Patient Require Nursing Care? *
Please give a few options
Desired Destination
A Week Away is designed to give the patient and their care team time away to recuperate and relax. We understand that everyone has different ways of relaxing, having fun and finding peace, so please select a category that best reflects your ideal time away.
It is our goal as an organization to assist as many families as we are financially able to each year. In order to accomplish this goal, include only the names of the patient's immediate care team to be considered to attend the respite. A Week Away defines immediate care team as family members or friends that have played an integral part in the patient's care since the time of their diagnosis. As such, include a brief description of the role each family member (excluding immediate family) or friend plays in the treatment of the patient.
Does the Patient or Anyone Attending the Respite Have Any Physical Limitations or Require Special Accommodations? *
Are You Applying For Opportunity Cost Coverage? *
We understand that treatments can often lead to financial hardships. In order to make your week away as stress free as possible, we may be able to cover a portion of lost wages that this respite may cause. If you choose to apply for opportunity costs, we will need you to include copies of your last two pay stubs and the most recent W-2 of any working, non-dependent family member. We will also be requesting your last 3 months financial statements. Please note that in order for A Week Away to cover lost wages, all PTO and/or vacation time must be exhausted. Proof of time off from your employer will be required.

After submitting your completed application, one of our representatives will be in contact with you in regards to additional documents that will be needed to process your request.