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 provides a note confirming the child's life-threatening medical condition
and deems the child medically able to participate in the Dream

To be eligible for a Dream, the child must reside on Vancouver Island or the Gulf Islands.
Child's Information
Child's First Name *
Child's Last Name *
Gender *
Child's Birth Date *
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DD
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Parent/Guardian's First Name *
Parent/Guardian's Last Name *
Parent/Guardian's First Name
Parent/Guardian's Last Name
Address *
City *
Postal Code *
Contact Phone number *
Parent / Guardian's Email *
Second Contact Phone number (optional)
Physician's Name *
Physician's Phone number
Child's Condition *
Dream Request *
Comments
Has the child had a Dream (wish) granted by any other organization? *
If yes, name of organization
Your First Name *
Your Last Name *
Your Contact Phone number: *
Your Email *
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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Submit
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