Dream 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. We tailor each Dream to provide a child and their family with the experience of a lifetime. Never underestimate the power of a Dream, it can be transformational: We make impossible, possible.

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

Eligibility for a Dream:

• The child is between the ages of 3 and 18
• The child has a life-threatening medical condition
• The child is a legal Canadian resident
• The child has not received a prior Dream (wish) from another organization
• The child's treating physician deems the child medically able to participate in the Dream

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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DD
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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
Dream Request
Your answer
Comments
Your answer
Has the child had a Dream (wish) granted by any other organization?
If yes, name of organization
Your answer
Terms of Agreement for Dream Request
This Dream 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 Dream initiative.

Privacy Policy:

Help Fill A Dream respects the privacy of our Dream 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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