Magical Experience Ask - Ben Stelter Foundation

Ben was fortunate to have so many magical experiences during his fight. We want to make sure other children can have moments to escape reality and make life-long memories with their families. Do you have a child or know of a child that is eligible and would benefit from a Magical Experience? *Please note that at this time, we will not be creating out of Province travel experiences. 

Eligibility

  • The Child is between the ages of 3 and 17 

  • The Child is currently battling a life-threatening condition of cancer that meets our eligibility criteria

  • The Child must be an Canadian resident

Privacy Policy

The Ben Stelter Foundation respects the privacy of our children and their families. All medical and personal information is kept confidential and is not shared with outside parties unless consent is provided by the child’s parents or guardians. 


Sign in to Google to save your progress. Learn more
Email *
Your Name *
Phone # *

Your Relationship with the child? (Parent/Guardian, Medical Professional)

Please note: Out of respect for the privacy of the children and families we serve, children must be referred by specific individuals (Parent/Guardian or Medical Professional). If you do not fall into one of these options, please ask the child's family to visit our website, or contact our office at mike@benstelterfund.com

 *
Child's Name *
Child's Gender *
Child's Age (1-17 years old) *
Does the child have mobility restrictions *
Is the child actively in treatment *
Child's Medical Condition (include as many details including date of diagnosis, current state, and physician's name and hospital assigned to / treatment hospital) *
Parent/Guardian details (include name, address, email and phone #) *
Details of siblings (indicate how many, ages of each, etc.) *
Has the child received a Wish or Experience granted by another organization? *

Please tell us about the child and what their interests and hobbies are.

 *

What are the child’s top 3 magical experience requests?

 *

What is the estimate value (in Canadian dollars) of the requested Magical Experience?

 *

Is there anything else you would like us to know?

How did you hear about the Ben Stelter Foundation?

 *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms