Application for Families - Children's Dream Fund

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Application for Families

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Application for Families

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Dream Child Information

Full Name of Child *

First

Middle

Last

Date of Birth *

Age *

Gender *

Illness *

Diagnosis Date *

Race *

T-Shirt Size *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Legal Mother's Full Name *

Legal Father's Full Name *

Does the child reside with both biological parents? *

Yes
No

If no, with whom do they reside?

Who has custody of the child?

Mother
Father
Joint
Other

Please specify

Physician & Medical Information

Hospital *

Clinic *

Physician Name *

Email *

Social Worker

Email

Child Life

Email

Legal Guardian 1 Information

Full Name *

First

Middle

Last

Are you primary contact? *

Yes
No

Date of Birth *

Relationship to Child *

Mother
Father
Other

Other

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Phone Number Type *

Secondary Phone

Phone Number Type

Email Address *

Occupation *

Primary Language *

Marital Status *

T-Shirt Size *

Legal Guardian 2 Information

Full Name

First

Middle

Last

Are you primary contact?

Yes
No

Date of Birth

Relationship to Child

Mother
Father
Other

Other

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone

Phone Number Type

Secondary Phone

Phone Number Type

Email Address

Occupation

Primary Language

Marital Status

T-Shirt Size

Sibling Information

Sibling's Full Name

Relationship

Age

Date of Birth

T-Shirt Size

Legal Parent(s) Name(s):

Who has custody of the child?

Dream Information

Has the child ever received a wish from another organization? *

Yes
No

If yes, with whom?

How did you hear about The Children's Dream Fund? *

A Dream Coordinator will be meeting with you and your child to discuss his/her dream. Your child's dream idea does not need to be decided at this time, but if they have ideas, please briefly describe:

Dream Idea 1

Dream Idea 2

Participation Authorizations & Releases

Authorization and Release *

I do hereby request the Children’s Dream Fund to grant my (our) child’s dream set forth in the application submitted to the organization. I hereby authorize the Children’s Dream Fund to contact my child’s physician concerning my child’s illness and authorize the physician to release any and all medical information concerning the child, necessary for the Children’s Dream Fund to attempt to grant the child’s dream. I (we) further acknowledge and accept that there are certain risks to me (us) that may arise from participating in the activities of the Children’s Dream Fund including, but not limited to, risks associated with potential exposure to communicable diseases such as COVID-19, and I (we) knowingly and voluntarily assume full responsibility for any and all risk of personal or bodily injury, death, or any other damage or loss that I (we) may sustain. In consideration for participating in Children’s Dream Fund Activities, I (we), for myself and for my minor child or ward, and on behalf of my (our) heirs, assigns, beneficiaries, executors, administrators, personal representatives, and next of kin expressly release, indemnify and hold harmless the Children’s Dream Fund, its volunteers, officers, directors, agents, servants, representatives, employees, and dream participants (the “Released Parties”) from any damages, claims, demands, suits, causes of action, losses or liabilities, of any kind whatsoever, arising out of the activities of the Children’s Dream Fund, whether from the negligence of the Released Parties or otherwise, to the fullest extent permitted by law. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

I authorize the Children's Dream Fund to release any information concerning the above-named child about his/her dream, illness or any related information to the below named outlets. If marked yes for news/print/video media, you are further authorizing the Children's Dream Fund to present to the general public any information and/or any photographs, recording, interviews and similar information which the media may gather about the above named child, his/his illness and the efforts of the Children's Dream Fund to assist the child and his/her family. *

Yes
No

concerning you on

I authorize the Children’s Dream Fund to use my child’s photo(s) and/or story on the organization’s website, newsletter, and social media; in reprints shared with hospital staff, in-kind donors, and dream families; and in potential news media such as television, newspaper, radio, or other communications and advertising mediums. *

Yes
No

I authorize the Children’s Dream Fund to share my child’s photo(s) and/or information with their dream sponsor. *

Yes
No

The Children’s Dream Fund is a 501(c)(3)
EIN #59-2145821 | State of Florida Registration #CH1278

Contact

1600 23rd Avenue N
St. Petersburg, FL 33713
(727) 896-6390
info@childrensdreamfund.org

Dreams

I Dream to Be
I Dream to Go
I Dream to Have
I Dream to Meet

Rating

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Name Full Layout

Full Name *

Email *

By submitting this form, you are consenting to receive marketing emails from: The Children's Dream Fund, 1600 23rd Avenue N, Saint Petersburg, FL, 33713-4428, US, www.childrensdreamfund.org. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact.

Financial Information

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About Us
How It Works
View All Dreams
Make A Dream Come True
- Ways to Give
Get Involved
Events & News
- Upcoming Events
- In the News