APPLICATION FOR A WISH

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Turning Dreams Into Memories
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Applicant's Full Name
Please provide applicants date of birth.
Applicant's Address
Please provide your phone number.
Emergency Contact
Please provide the name of an emergency contact.
Specify the relationship of the emergency contact to the applicant.
How did you hear about us?

Medical

Physicians Name
Clear Signature
I certify that I am the treating physician of the Applicant. To the best of my knowledge, my patient has a limited life expectancy. I certify that my patient is of sound mind, and capable to sign legal documents. I have discussed (or will discuss) the wish request with my patient and have deemed it safe and reasonable if his/her wish is granted within the next three months.
Mobility
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Your Wish

Has applicant ever been granted a wish by Buckit!JLC or any other organization?
Is an application submitted or pending with another wish-granting organization?
Does applicant have a valid drivers license or state ID?
Please describe the wish you would like to have granted.
Explain why this wish is important to you, who you would like to include, and what help is needed from Buckit!JLC to facilitate the wish.
Sometimes due to legal, financial, or medical restrictions, we may not be able to grant your first choice for a bucket list wish.
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