Please review our guidelines at the end of the application to make sure your wish meets our criteria. Wishes that do not meet our criteria will not be considered for fulfillment. If you are nominating a senior for a wish, please remember that all questions refer to the senior you are nominating. Please be as thorough as possible to ensure your application is considered.
Section A: Senior's Information

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* 1. Name

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* 2. Phone Number

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* 3. Address

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* 4. City

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* 5. State

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* 6. Zip Code

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* 7. Birthdate
Please note: Nominees must be 65 years of age or older

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* 8. Email Address

Nominator's Information (if applicable)

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* 9. Nominator Name

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* 10. Nominator Phone Number

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* 11. Address

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* 12. City

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* 13. State

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* 14. Zip Code

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* 15. Email Address

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* 16. Relationship to Wish Nominee

Section B: Wish Details for Nominee
*Please be specific in your answers, and include as much detail as possible.

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* 17. What is your Wish of a Lifetime?

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* 18. Explain the history behind this wish.
For example: What prompted this wish? Do you know how long you have wished for this? What is the story behind this wish? When did you know or first realize you wanted this wish?

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* 19. Describe any mental, emotional, physical or spiritual benefits you will experience as a result of having this wish granted.

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* 20. How would granting this wish inspire others and help Home Care Assistance in our mission to change the way people view aging?

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* 21. What has prevented you from fulfilling this wish on your own?
Have you done this before? If so, how long has it been? If you are looking to reconnect with someone, when was the last time you saw him or her?

Section C: Personal History of Nominee
Before we move forward with a wish, we would like to try and get to know you. Please take the time to tell us a little about yourself.

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* 22. What were your past occupations, if any?

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* 23. What are some of your interests, hobbies, and passions? Do you still participate in any of these today?

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* 24. What have you done to give back to others?
What volunteer work do you do now or have you done in the past? Please specify what organizations you volunteered for and for how long. If you were a member of the military, please list branch and describe your service. Include your duties and list any battles or campaigns you were a part of as well as any medals or honors you received.

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* 25. Have you ever been convicted of a crime?

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* 26. If you have been convicted of a crime, please provide details.

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* 27. Are you a legal resident or citizen of the U.S.?

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* 28. Do you have any physical or cognitive impairments that may influence your ability to participate in the wish?

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* 29. If yes, please describe, and let us know what accommodations will need to be made to enable you to participate.

Guidelines and Qualifications:

• A Legal Resident or Citizen of the United States of America
• Unable to fulfill the wish on your own
• Physically and psychologically able to experience the wish
• Not convicted of a crime
• Able to obtain approval from a doctor, if necessary
• Minimum age of 65
What Will Not be Granted or Considered:

• Financial assistance (cash payment of bills, rent, taxes, etc.)
• Housing assistance (home repair/modification, assistance moving, locating housing, etc.)
• Home furnishings
• Technology (computers, phones, cell phones, tv's)
• Medical care or services
• Legal services
• Vehicle (purchase, repair, modification)
• Potentially harmful or dangerous wishes
• Wishes on behalf of others under 65
A note about travel: When it comes to travel, it must be purpose-driven with a dream achieved during or as a result of the trip
Disclaimer:

Unfortunately, Home Care Assistance is unable to sponsor every wish we receive. The decision to grant a wish is at the discretion of Home Care Assistance and Wish of a Lifetime; a wish may be denied for any reason.

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