Bucket List Dream Application

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.

Have you reviewed the Bucket List – Live a Dream SOP before completing this submission?Click here to review the SOP

Has your campus had a Bucket List – Live a Dream approved within the last 12 months?

(Please note that each campus is generally limited to one approved Bucket List – Live a Dream every 12 months. If your campus has already received an approved dream within the past year, this request will likely be denied.)

Recipient and Dream Information

Bucket List Dream Status?

Please Select Campus

Dream Recipient First And Last Name

Dream Recipient Date of Birth

Estimated Cost

What is the Resident Payer Source?

Is the Resident on Hospice?

Which Service Line is the resident living on?

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

Which Of The Following Describes Your Dream The Closest

If Other Please Describe

Please provide a Short Summary of the Dream

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

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.

Anticipated Date of Dream

Your Relationship To Resident

Is the Resident in Need of Wheelchair access

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

Is the resident physically and medically able to participate in the travel required to fulfill this dream? (If you are unsure, please consult with the campus clinical team before submitting this request.)

Is this dream time-sensitive for any reason?

Please note that the approval process for a Bucket List – Live a Dream request typically takes 1–5 weeks. Once approved, an additional 1–2 weeks may be needed for planning, coordination, and the purchase of any necessary items. Please provide details if there is a specific date or circumstance that requires expedited consideration.

Why is this dream time sensitive

Why is this dream is time sensitive.

Guardian/ Family Information

How many family members are planning to join this dream?

Family members are welcome to participate; however, the Foundation is unable to cover any expenses for family members. All travel, lodging, meals, tickets, and other related costs for family members are their responsibility.

How many guardians( Trilogy Staff) are needed to support this resident during their dream?

Bucket List Live a Dreams are limited to one guardian (Trilogy team member) per resident. Additional support may be approved when necessary for medical needs, such as a nurse, or operational requirements, such as a driver.

Guardian One (Trilogy Team Member)

Guardian First and Last Name

Guardian Date of Birth (Required only if airfare will be booked)

Only needed if booking flights

Guardian Gender (Only needed if booking flights)

Only needed if booking flights

Guardian Email (If Known)

Relationship of Guardian

Guardian Phone Number (If Known)

Guardian - Hotel Room (If a hotel stay is required for this Live a Dream, should the guardian stay in the same room as the resident or in a separate room? Please consider any medical or physical support needs.)

Guardian Two

Guardian First and Last Name

Guardian Gender (Only needed if booking flights)

Only needed if booking flights

Guardian Date of Birth (Required only if airfare will be booked)

Only needed if booking flights

Guardian Email (If Known)

Relationship of Guardian

Guardian Phone Number (If Known)

Submitter Information

Submitter First & Last Name

Submitter Title

Submitter Email

Campus Life Enrichment Director Email

Phone

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