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.

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Type Of Dream

Please Select Campus

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

Bucket List Dream Status?

Dream Details

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.

Please provide a Short Summary of the Dream

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

Bucket List Dream

Which Of The Following Describes Your Dream The Closest

If Other Please Describe

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 Date of Dream

Is this dream time sensitive for any reason?

Why is this dream time sensitive

Why is this dream is time sensitive.

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