Tell Us Your Dream
| Applicant's First Name: | Applicant's Last Name: | ||
|---|---|---|---|
| Address: | |||
| City: | Postal Code: | ||
| Phone Number: | Age: | ||
| Parent’s First Name: | Parent’s Last Name: | ||
| Address: | |||
| City: | Postal Code: | ||
| Phone Number: | Email: | ||
| Physician’s Name: | Phone Number: | ||
| Address: | |||
| City: | Postal Code: | ||
| Type of Illness: | |||
| Type of Dream: | |||
All applications will be held in strict confidence within the Foundation.
Each applicant will be handled on a personal basis, with the assistance of the parent(s) and the physician.
NOTE: A letter from the child's physician must accompany this application.