How to Apply

To apply, send the following information to or 214 Longstreet Hall, University, MS, 38677:

  • Your name, home address, and home and/or cell phone number
  • Your university school/department, classification, and work phone number
  • The name of your immediate supervisor/director/chair
  • The name, age, and gender of the dependent in need of medical attention
  • The number of family members traveling for this situation
  • Basic information about your situation, including information about the legal dependent for whom you are seeking support (it is not necessary to give detailed medical information)
  • Specifics about support you are requesting for hotel, airline tickets, fuel costs, meals, childcare, etc. (see example below)
  • The name and phone number of the physician who will provide documentation of the medical condition

Please have a certified physician fax documentation of the medical condition to 662-915-1288. The documentation does not have to include a diagnosis, only that your legal dependent has a medical problem.

The Committee will need to know the date funds are needed by you. Please indicate if the medical condition is predicted to extend over a long period of time, resulting in multiple out-of-town visits to medical facilities.

All information you provide will be held in strict confidence by the Committee and its members.

When the completed application and medical documentation have been received, the Committee will meet as soon as possible to determine eligibility for support. You will be notified immediately of the decision.

Here is an example of the type of information you should provide:

My child has been referred to the Mayo Clinic in Minneapolis, Minnesota. Surgery is required. Our appointment is on ________ date, and we anticipate a stay of _______ days. I/My family need(s) help acquiring airline tickets, lodging, and meals while we are at the clinic.

  • Estimated fuel costs = _______________
  • Each airline ticket = $_________x number of people traveling = _____________
  • Hotel/room price = $_________x how many days = _______________
  • Estimated meal costs = _________________
  • Other = $_________ (please identify ____________________________)
  • Total estimated expense = $_________