Dream Application Form

Never underestimate the power of a Dream, it can be transformational. Completing the ‘Request A Dream’ application form is your chance to tell us why this child deserves a Dream, and what would be the experience of a lifetime for them. Each Dream that we fulfill is as unique as the child it is created for.

Anyone can refer an eligible child for a Dream 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.

Please complete steps 1-4 of the form. If you have any questions email [email protected] or call 250-382-3135

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.

Step 1 of 4 - Child

Child's Name*
First Last
Gender*
- Male
- Female
- Nonbinary
Specify pronoun, if desired
Child's Birth Date*
YYYY slash MM slash DD

Parent/Guardian's Name*
First Last
Parent/Guardian's Name
First Last
Address*
Street Address City Postal Code

To be eligible for a Dream the child must reside on Vancouver Island or the Gulf Islands.
Contact Phone Number*
Second Contact Phone Number (optional)
Parent/Guardian's Email*
Physician's Name*
First Last
Physician's Phone Number*

Child's Condition*
Physician's note or medical records required prior to approval of Dream.
Dream Request*
Comments
Has the child had a Dream (wish) granted by any other organization?
- Yes
- No
- Don't know
If yes, name of organization*

Nominator's Name
First Last
Nominator's Phone Number*
Nominator's Email Address*
Phone
This field is for validation purposes and should be left unchanged.