Quality of Life Initiative Application Form

Unit D - 4085 Quadra St
Victoria BC V8X 1K5
T: 250-382-3135 | TF (BC Only): 1-866-382-2711
F: 250-382-2711
helpfilladream.com


Please complete the following information and should you have any questions,
please email at contact@helpfilladream.com or call 250-382-3135

Inspiring hope, help and happiness
Thank you for your interest in Help Fill A Dream. Our Quality of Life program provides focused funding for the improved mobility, health and well-being of a child, and medical treatment that involves travel outside of the province or country. Recent examples include: the purchase of an oximeter and an insulin pump, travel to Chicago for an operation, a private tutor for an immune-suppressed child, an iPad to assist with learning and communication, and home and vehicle modifications to accommodate a wheelchair and other special needs. Each request is as unique as the child it will benefit.

Children who may be eligible for a Quality of Life may be referred by anyone, including social workers, healthcare professionals, community organizations, relatives, friends or other Quality of Life families. The child's family will always be contacted once a referral is made and before proceeding with the Quality of Life initiative.

To apply, the child must be a resident of Vancouver Island or the Gulf Islands.

Eligibility for a Quality of Life:

• The child is under the age of 19
• The child has a life-threatening medical condition supported by a doctor's note
• The child is a legal Canadian resident

Your First Name *
Your answer
Your Last Name *
Your answer
Your Contact Phone number: *
Your answer
Your Email *
Your answer
Child's Information
Child's First Name *
Your answer
Child's Last Name *
Your answer
Gender *
Child's Birth Date *
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Parent/Guardian's First Name *
Your answer
Parent/Guardian's Last Name *
Your answer
Parent/Guardian's First Name
Your answer
Parent/Guardian's Last Name
Your answer
Address *
Your answer
City *
Your answer
Postal Code *
Your answer
Contact Phone number *
Your answer
Parent / Guardian's Email *
Your answer
Second Contact Phone number (optional)
Your answer
Physician's Name *
Your answer
Physician's Phone number
Your answer
Child's Condition *
Your answer
Quality of Life Initiative *
Your answer
Comments
Your answer
Terms of Agreement for Quality of Life Initiative
This Quality of Life initiative is solely funded by the Help Fill A Dream Foundation of Canada. The parent(s) or guardian(s) will not hold Help Fill A Dream Foundation, or its officers, responsible for any accident(s), acts of God or unforeseen illness that should occur during this Quality of Life initiative.

Privacy Policy:

Help Fill A Dream respects the privacy of our children and their families. All personal and medical information is kept confidential and is not shared without the express written consent of the child's parents or guardians.

I have read and agree with these guidelines *
Date *
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