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#DREAMDAY Application
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Who is completing this form?
Recipient
Recipient's Parent/Guardian
General Practitioner
Other:
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RECIPIENT INFORMATION
Name:
Your answer
Age:
Your answer
Gender:
Female
Male
Transgender Female
Transgender Male
Gender Variant/Non-conforming
Prefer not to answer
Other:
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City:
Your answer
State:
Your answer
Instagram Username:
Your answer
Phone:
Your answer
Email:
Your answer
Please give a short description of the recipient's Illness:
Your answer
How did you learn about the #DREAMDAY program?
Your answer
Please share about how the recipient is "Living The Dream" despite battling a life-threatening illness.
Your answer
Please list a few of your favorite bands or music artists.
Your answer
Does the recipient have problems with communication?
Yes
No
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MEDICAL PROFESSIONAL INFORMATION
Medical doctor, specialist, or general practitioner. This information is used to confirm your condition.
Hospital:
Your answer
Medical Professional's Name:
Your answer
Medical Professional's Address:
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Medical Professional's Phone:
Your answer
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