Live a Dream Application/Submission

Our mission is to strive to serve our residents to the best of our ability, to embrace their passions, and to give back a little piece of what they have given, and continue to give.

Click here for bucket list dream form:

https://trilogy.tfaforms.net/4858552

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Type Of Dream

What Kind Of Dream Are You Interested In Pursuing

*For More Information On Each Type Of Dream Please Click Here

Please Select Campus

Dream Status?

What is the Resident Payer Source?

Private pay residents who have end-of-life diagnoses and/or physical/mental limitations that would require a caregiver to accompany the resident during dreams (i.e. usage of wheelchair, help with administering medications, etc.)

Does the resident have an end-of-life diagnoses and/or physical/mental limitations?

Is the Resident on Hospice?

Which Service Line is the resident living on?

Estimated Cost

Honor Flight Application Status

Dream Details

Please Note!

For Local Campus Dreams, please only come back to fill out this application once the Live a Dream has been completed. Please do not put in progress for the dream status.

Describe Dream Requested And What It Would Mean To The Resident:

*These Details Will Be Carefully Considered, More Details Will Increase The Chance Of Selection And Funding.

For Local Campus Dreams, please only come back to fill out this application once the Live a Dream has been completed. Please do not put in progress for the dream status.

Please provide a Short Summary of the Dream

Example: Go Sky Diving, Visit Niagara Falls, or Attend Granddaughter's Wedding

Campus Dream

Category Of Dream

If Other Please Describe:

DreamVR

DreamVR Experience

If you selected "other," please share the DreamVR experience you completed.

Number of Resident who experienced DreamVR

Additional Comments/Story

If you have a story or additional comments to add about this experience, please submit those here.

Recipient Information

Your Relationship To Resident

Dream Recipient First And Last Name

Is the Resident in Need of Wheelchair access

Resident Facility Type

Resident Birthday (If Known)

(MM/DD/YEAR)

Can this dream be executed within 4 days, including travel time?

Guardian Information

How Many Guardians Does This Resident Want To Experience this Dream With?

How many guardians are needed to support this resident during their dream?

Guardian One

Guardian First and Last Name

Guardian Email (If Known)

Relationship of Guardian

Guardian Phone Number (If Known)

Guardian Two

Guardian First and Last Name

Guardian Email (If Known)

Relationship of Guardian

Guardian Phone Number (If Known)

General Information

Submitter First & Last Name

Submitter Email

Campus Life Enrichment Director Email

Phone

Anticipated or Completed Date of Dream

Is this dream time sensitive for any reason?

Why is this dream time sensitive

Why is this dream is time sensitive.

Honor Flight

Please Select Which Honor Flight Chapter Campus

*If You Do Not See Your Honor Flight Chapter Listed Here, Please Contact Your LED Or The Home Office So That We Can Add It.

In which is the earliest war that this Veteran served?

If Other Please Specify:

Do you know who the guardian will be?

*Honor flight requires a guardian to attend that is not a spouse, do you know...

Guardian Information

Guardian First and Last Name

What Relation Is The Guardian To The Recipient? (If Known)

How Much Is The Guardian Fee?

If other, please state here:

Guardian Phone Number (If Known)

Guardian Email (If Known)

Misc.

I consent for Live A Dream to use this dream for marketing purposes.

*Saying "No" does not disqualify this dream submission from happening.

I would like to remain anonymous to dream recipient.

Optional Photos

Please feel free to attach any photos relevant to this application.

Contact Information