Trips, Dreams & Memories Foundation


Important Instructions Anyone can nominate a family for our program. Please review our Eligibility Criteria prior to nominating a family. All fields must be completed in order for the family to be considered. Complete nominations will be reviewed within 7 business days. You will be notified of the status of your nomination by mail within 10 business days. If the family meets our minimum criteria, they will be invited to complete a program application.
Your Contact Information (Person who is nominating the family)
First Name *		Last Name
E-mail *
Address
City		State	Zip
Phone
Relationship	Self/Spouse Family Friend Co-Worker/Employer Church	Healthcare Provider Neighbor Teacher Other
I am interested in: (Mark all activities you are interested in)
	Helping with mailings Helping with special events	Fund raising Phone calls Other
Is the family aware you are nominating them for the program?
May we tell the family who nominated them for the program?
Family Information (information on the family you are nominating)
First Name *		Last Name
Spouse Name *		please list last name if different from Nominee's
Child Name		Approximate Age
Child Name		Approximate Age
Child Name		Approximate Age
Child Name		Approximate Age
Additional Children list name and age for each additional child
Address
City		State	Zip
Phone
Brief description of medical condition/diagnosis
What do you feel the life expectancy is? 1 year or more 6 months to 1 year Less than 6 months unknown
Tell us why you are nominating this family for our program
Date

If you have questions or need immediate assistance, please contact us.