Children’s Application

Eligibility Requirements: Children ages 6-18 yrs., U.S. Citizen, with life-altering medical or social conditions, No previous grants for outdoor adventures. Depending on the individual wish – local sporting regulations will apply. Age exceptions may be made to accommodate injured U.S. military personnel/veterans. Please fill out the application in it’s entirety.
Form must be signed by parent or legal guardian.

CHILD'S PERSONAL INFORMATION

First Name

Last Name

Child prefers to be called (nickname)

Date of Birth

Last 4 digits of S.S.#

Gender (male, female)

Height

Weight

Eye Color

Shirt Size

Pants Size

Shoe Size

Right or Left Handed

Race

U.S. Military

If yes what branch

Does the child have a website dedicated to his/her medical condition

Web Address

Please provide brief description of childs life-altering medical or social condition

Provide any physical limitations or special needs that need to be taken into consideration based on the child’s wish

Current Treatments needed that may limit child’s availability for a granted wish (please include frequency of treatments & when the next treatment is scheduled)

When would child be available, if chosen, to participate in a One Wish Foundation outdoor adventure?

Has child ever received any type of wish / grant for an outdoor adventure?

If Yes – Which organization?

When

What wish was granted or requested?

Does child have any application in currently with any other organization?

Organization

Briefly describe the child’s top three wishes

If child’s wishes involve a hunting / fishing adventure – has the child ever participated in these activities before?

Briefly explain child’s level of experience:

Has child completed a regulated Hunter’s Safety Course?

If Yes - State

Certificate #

MEDICAL VERIFICATION

MEDICAL VERIFICATION: Child’s attending physician

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Fax Number

Due to current privacy regulations, the One Wish Foundation requires the parent's / legal guardian’s permission to contact your child’s physician. Please sign below if you agree with the following statement: I hereby grant the One Wish Foundation permission to contact my child’s attending physician regarding my child’s medical condition. I further grant permission for the physician, listed above, to release the required information and/or speak to the One Wish Foundation regarding my child’s medical condition. If your child has more than one primary physician - please include information on an additional sheet.

Signature of Parent or Guardian ( Type in Name )

Date

Does child receive help from a Social Worker or any other Specialists?

If Yes – please provide contact information below.

Name

Name of affiliation

Address

Address Line 1

Address Line 2

City

State

Zip Code

Signature of Parent or Guardian ( Type in Name )

Date

PARENT/GUARDIAN CONTACT INFORMATION

PARENT/GUARDIAN CONTACT INFORMATION: Fathers Name

Home / Cell # (Primary)

Work #

Address

Address Line 1

Address Line 2

City

State

Zip Code

E-mail

Fax #

Mothers Name

Home / Cell # (Primary)

Work #

Address

Address Line 1

Address Line 2

City

State

Zip Code

E-mail

Fax #

Legal Guardian’s Information – if not parents

Name

Home / Cell # (Primary)

Work #

Address

Address Line 1

Address Line 2

City

State

Zip Code

E-mail

Fax #

List full names of siblings and ages that are living at same household as applicant:

If parents are divorced or separated – which parent does the child live with?

Does this parent have legal custody of the child?

If child lives with legal guardian – please explain relationship:

Additional Contact(s) – in case we are unable to reach you:

PARTICIPATION WAIVERS

PARTICIPATION WAIVERS: If the child is approved for a One Wish Foundation “One Wish Outdoor Adventure” will the parents / guardian be willing to sign a Waiver of Liability? (If Yes – a copy of the Waiver of Liability will be sent to you for the proper signatures.)

Part of our vision is to provide a memory that lasts forever and the ability to help others. If your child is approved for a One Wish Foundation “One Wish Outdoor Adventure” do we have your permission to take video footage of your child’s adventure and story? We request this permission in order to preserve his/her memory forever. You will receive a copy of your child’s video, a copy of the video will be preserved on our website for all visitors to see, and we may even have the opportunity to air your child’s story on national television. In our efforts to help others – your physicians description of your child’s story may bring awareness to others who may be experiencing the same issues.

Do you grant the One Wish Foundation permission to show your child’s story on our website and/or television?

Signature of Parent or Guardian ( Type in Name )

Date

INFORMATION ON INDIVIDUAL COMPLETING THIS FORM

INFORMATION ON INDIVIDUAL COMPLETING THIS FORM: Name

Home / Cell # (Primary)

Work #

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Fax #

Relationship to child

How did you hear about the One Wish Foundation?

Date Application is submitted

If you have any questions – please contact:
Jarrod Renninger
President & Founder
E-mail: mrr803@comcast.net
E-mail: jarrod.renninger@onewishfoundation.org

Special Note: Everyone at the One Wish Foundation would like to personally thank-you for taking the time to learn about our organization and submit an application to us. If we had “one” wish of our own it would be to grant every application that is submitted. Unfortunately, it is impossible for us to do that due to the limitations on donated funds, limited resources and amount of available time provided by our officers, board members, and volunteers.
We give you our promise that your application will be given our full attention and that if you are selected you will be contacted within 90 days from the date the application was submitted. If you do not hear from us within 90 days we will keep your application on file for future election.
Thank you for your understanding in this matter.