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Congratulations on your selection as a DAISY Medical Mission Grant recipient! Please complete and submit the information below within 30 days of your return from your mission.

Mission Trip Details

Your Medical Mission Grant Application Number (located in the email sent with your liability waiver form). If you can't find it, please email Faith Thomas at: FaithThomas@daisyfoundation.org

Your Name:

Start Date of Your Participation in the Mission:

End Date of Your Participation in the Mission:

Location of Mission:

Please describe in detail the impact of the mission in providing healthcare to the area you visited:

Please provide the details of your specific contributions to the mission, including your nursing skills/specialty and your perspective as a DAISY Award recipient:

Please upload photos from the mission. Your photos and mission details may be used in any/all future DAISY communications and publications. If you have any issues with attachments, please email them directly to FaithThomas@DAISYFoundation.org

Photo 1:

Photo 2:

Photo 3:

Photo 4:

Photo 5:

Reimbursement Reminders

You must provide adequate documentation supporting the expenses and their purpose to be reimbursed, and clearly highlight those items on the receipt.
Only your direct costs are reimbursable. Salary and vacation time are not reimbursable.
Alcoholic beverages are not reimbursable.

Required documentation:

Meals –Itemized receipt including the date, amount, and name of the restaurant/establishment.

Air/Rail –Itinerary or electronic tickets showing it has been paid, or a copy of the ticket(s) and your credit card statement with the transaction and amount indicated.

Hotel – Itemized hotel bill showing proof of payment.

Car Rental – Car rental agreement receipt showing proof of payment.

On-line transactions – Itemized list that includes proof of payment

Missing Receipt - Provide a signed statement with a complete explanation of the expense if a duplicate copy of the original receipt is unobtainable.

Copies of cancelled checks may be used to support reimbursement of expenses paid from a personal checking account.

Reimbursement Submission

Reimbursement Process:

2 forms are required for reimbursement. (1) A PDF document with your scanned receipts/proof of payment (see details below). (2) An Excel spreadsheet of cost breakdown. Please use our spreadsheet template available here.

Amount Requested From DAISY? (Not to exceed $1,500.00)

Please attach your PDF document with scanned receipts here.

Please attach the excel spreadsheet with cost breakdown here.

Reimbursement check should be sent to you at the following address:

Address Line 1

Apartment, Unit, Building if needed:

City

Country

State

Provinces

State/Province

Postal Code

Thank you for sharing your clinical expertise and extraordinary compassion by participating in a medical mission! We will process this information and be in touch with any questions.

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