Dear Social Worker,
Thank you for considering to refer one of your patients for a Dream. We look
forward to working on this request and to learning more about your patient.
In an eort to gather data that will help us measure the quality-of-life impact
Dreams have on a patient and their end-of-life care, we are asking referrers to
complete a short questionnaire. The questions are part of the World Health
Organization’s Well-Being Index (WHO-5), which was originally presented in 1998
as part of a project on the measurement of well-being in primary health care
patients. It has shown to be a reliable measure of both positive and negative
Would you please consider asking your patient ve simple questions before
starting to explore the possibility of a Dream?
We ask that you record your patients WHO-5 answers before discussing a Dream
with them, and then again a few weeks after the Dream is completed. We are
very aware of your workload, and the WHO-5 can be administered in 2-3 minutes.
Thank you very much for supporting us in our eort to collect meaningful data on
the impact of Dreams!
Dream Foundation Team
PHONE 888-4DREAMS | 888-437-3267 | 805-564-2131 | FAX 805-564-7002
Patient Name:
Please indicate for each of the ve statements which is closest to how you have
been feeling over the last two weeks. Notice that higher numbers mean better
Example: For line 1, if you have felt cheerful and in good spirits more than half of
the time during the last two weeks, check the corresponding box.
Over the last two weeks
All of
of the
than half
of the
than half
of the
of the
At no
I have felt cheerful and in
good spirits
I have felt calm and relaxed
I have felt active and
I woke up feeling fresh and
My daily life has been lled
with things that interest me
Thank you for helping us to gather data on the impact of Dreams on patients
nationwide. This questionnaire is anonymous, and only the data collected will be
shared. Please email the questionnaire to or mail to
Dream Foundation, 1528 Chapala St. #304, Santa Barbara, CA 93101
Dream Foundation Team
PHONE 888-4DREAMS | 888-437-3267 | 805-564-2131 | FAX 805-564-7002
Hospice Referral – Dream Request Application
Dream Applicant, friends or family members may not use this application; ONLY a hospice representative may submit this.
If the Dream Applicant is NOT under hospice care, please complete the General Application available on our web site.
Dear Hospice Representative,
Dream Foundation, the only national dream-granting organization for terminally-ill adults, fulfills final Dreams that
provide inspiration, comfort and closure at the end of life. With the support of a nationwide network of volunteers,
hospices, health care organizations and committed donors, Dream Foundation has given life to more than 30,000
final Dreams over the past two decades.
Help us to help you make the Dream come true...
Please read this form very carefully and follow all the instructions to complete all the steps necessary to
make your patient’s Dream come true.
Providing as accurate and current life expectancy as possible helps expedite application processing.
You will find many answers to your questions in our Frequently Asked Questions section.
Please submit all required information; incomplete applications will be denied.
We are unable to grant the following types of Dreams:
Requests for adults with chronic illnesseswith
the exception of individuals with a clinical
prognosis of 12 months or less
Requests from individuals living outside the
Surprise Dreams
Legal assistance
Cash/Financial assistance
Funeral arrangements or posthumous requests
Automobiles, Lifts, Repairs, RVs or Rentals
Travel outside the United States. However, on
a case-by-case basis we may allow one-way
travel to countries outside of the U.S. for
patients who wish to die at home and consider
travel to U.S. territories
Property and home improvements or repairs
Medical treatment/supplies/equipment/
Any Dream request in violation of the rules,
policies or procedures of our organization or
that of our corporate partners, in effect from
time to time
Please include these 3 items by mail, email or text: A photograph, personal letter & income.
Photograph: Must be clear and taken within the past year. It may include family, pet, etc
Letter: Must describe the Dream and its importance to the applicant. The letter should:
o Be 1-2 pages, clearly describe your Dream, its importance to you, what it means to you and where the
most help is needed to fulfill that Dream
Annual Income: We provide Dreams to those in the greatest of need. Send one of the following, e.g.
SSI/SSDI Statement, Bank Statement or hospice representative may attest to the need by initialing the
corresponding statement on the following page.
PHONE 888-4DREAMS (888) 437-3267
Hospice Referral Application
Legal Name of Patient: Email:
Address: City/State/Zip:
Phone: ( ) Cell: ( ) County:
Age: Date of Birth: Current Annual Household Income:
Gender: Ethnicity (Optional):
Military Veteran: Y or N Branch and Dates of Service:
Relative Contact Information: Relationship:
Phone: ( ) Email Address:
(Including City/State/Zip if different from above)
Dream Request:
Alternative Dream Request (Must be entirely unrelated to first Dream):
(If no alternate Dream is listed, only primary Dream request will be pursued)
Has Applicant ever been granted a Dream by another organization? Yes No
Does Applicant, or a participant in the Dream, have a well-funded credit or debit card for travel requests?
Yes No
Does Applicant, or a participant in Dream, have a valid driver’s license for travel requests? Yes No
Signature of Patient Date
This Bottom Portion to Be Completed by a Hospice Representative Only
Hospice Representative: E-Mail Address:
Office Phone: ( ) Cell Phone: ( ) Office Fax: ( )
Name of Hospice:
Address: City/State/Zip:
To the best of my knowledge I believe the Dream request will improve the quality of life for the patient/Dream recipient.
Need: I confirm that the applicant lacks the financial resources to fulfill this Dream on their own: [initial]
The CURRENT life expectancy, in months, for the patient is:
Signature of Hospice Representative Title Date
*IMPORTANT* No faxed applications will be accepted
Please have your patient sign and mail back to Dream Foundation
Waiver and Release of Liability
I, the undersigned social worker, recognize and acknowledge that there are risks involved in the granting of a Dream
by Dream Foundation, and I have informed my patients that they will assume the full liability of any, and all, injuries,
damages, or loss, regardless of severity, that they may sustain as a result of said participation, as outlined in the
Dream Agreement.
Signature of Hospice Representative Date
I, the undersigned Dream Recipient, hereby certify that the information contained in my application is true and
correct, that I have read, understand, and signed the attached Dream Agreement including permission to disclose my
medical condition to Dream Foundation. I grant permission for Dream Foundation or its service providers to perform
a background check on me. If I have requested a travel Dream, I understand that a major credit or debit card and
proper identification is required.
Signature of Dream Recipient Date
If applying online, this online facsimile signature shall substitute for, and have the same legal effect as, an original
form of signature.
Participants in my Dream (spouse/caregiver) Children under 18 years of age.
Dream Agreement
Please initial items 2, 3, 4, 5 and 20 where indicated, below:
1. Granting of Dream. Dream Foundation (“DF”) shall assist with the Dream requests for the person identified below
(“Recipient”) and Recipient’s immediate family members or caregiversuch as a spouse, significant other, caregiver,
mother, father, and/or dependent children who live in the home and are under the age of 18, subject to the terms and
conditions set forth in this agreement. DF reserves the right in its sole and absolute discretion, to decide if a Dream will
be granted and on what terms. DF shall have no obligation to fulfill any Dreams hereunder if it elects to terminate or
abandon such Dreams pursuant to section 10 below.
2. Permission to disclose medical condition. The Recipient grants DF the right to disclose the nature of his/her medical
condition to the extent necessary in the fulfillment of the Dream. Furthermore, the Recipient grants DF permission to obtain
medical information about the recipient which DF may feel necessary for fulfillment of the Dream and authorize all physicians
and medical care providers to provide DF with all medical information. [initial here]
3. Waiver. The Recipient and all participants hereby forever waive any and all rights or claims he or she may have or may
hereafter acquire against DF, its officers, directors, agents, and employees arising out of any injury, harm damage or loss
of any kind to body or property, including without limitation the transmission of infectious or communicable disease
and/or attorneys’ fees (collectively “Losses”) suffered or incurred by the Recipient, and any participant, arising out of or
in any way related to DF’s preparation, execution or fulfillment of the Dream, whether or not such Losses were caused
by the active, passive or gross negligence or omission of DF or any other person. [initial here]
4. Release. Recipient, and all participants, together, and each of them individually, do hereby forever release and hold DF,
its officers, directors, agents, and employees harmless from any and all Losses suffered or incurred by Recipient or any
participant arising out of or in any way related to DF’s preparation, execution or fulfillment of the Dream, whether or not
such Losses were caused by the active, passive or gross negligence of DF or any other person. [initial here]
5. Indemnity. Recipient, and all participants, jointly and severally, do hereby agree to indemnify and hold DF, its officers,
directors, agents, and employees harmless of and from any and all Losses suffered or incurred by DF, its officers,
directors, agents, and employees as the result of any claim, lawsuit, or action arising from the actions or omissions of
Recipient and any participant during the preparation, execution and fulfillment of the Dream, or due to a breach by
Recipient, or any participants, of the representations, warranties or covenants contained in this agreement. Said hold
harmless and indemnity includes, but is not limited to, reasonable attorneys’ fees and costs incurred by DF, it officers,
directors, agents, and employees in retaining attorneys of DF’s choice to defend any and all such claims, lawsuits, and
actions. [initial here]
6. Relatives/Friends. No person may accompany the Recipient during any portion of the Dream fulfillment, unless specifically
agreed to in writing between DF and Dream Recipient.
7. Dream expenses. The expenses DF has agreed to pay for are those foreseeable and directly related to the fulfillment of
the Dream. Dream Recipient, relatives or friends, together understand that they may be forced to incur substantial
expenses as a result of unforeseen events or circumstances beyond DF’s control, especially if fulfillment of the Dream
involves travel. DF shall not have any responsibility or liability for expenses incurred by Recipient, relatives or friends
which have not been expressly assumed by DF pursuant to this Agreement, which have been caused by unforeseen
events, or circumstances beyond DF’s control. For example, a particular Dream may contemplate DF paying for certain
specific expenses for a specific period of time while Recipient is traveling away from home. If Recipient’s medical
condition deteriorates so that immediate hospitalization is necessary, Recipient may be forced to remain away from
home longer than the period of time contemplated by the Dream. In that event, it will be the sole responsibility of the
Recipient to pay for all expenses in excess of those for which DF has agreed to pay, whether medically-related, for
meals and lodgings, including hospitalization, or for other goods, or services of any nature. If death occurs during
Dream, DF is unable to assist in any way.
8. Fundraising. As a participant in Dream Foundation program, if needed, a campaign may be undertaken in your
community, with your prior approval, to raise funds and/or frequent flyer miles to fulfill the Dream. Money raised will be
used for your Dream up to a maximum allocation as described in item 7. Funds or miles raised above the allocation for
your Dream will be used for future Dreams.
9. Representations and warranties. Recipient, relatives, friends, and participants, jointly and severally, make the following
representations and warranties to DF:
they have made a true and full disclosure of all medical conditions to DF;
all information contained in the application and any materials provided in support of the application are true and
correct in all material respects;
they will notify DF if and when Recipient’s medical condition should deteriorate at any time prior to fulfillment of the
they are carrying, or during the fulfillment of the Dream shall be carrying, full medical insurance, including any
additional coverage which may be required as a result of the Dream to be fulfilled, or that they assume the risk and
personal responsibility of failing to carry adequate medical insurance;
if fulfillment of the Dream involves travel, they are able to bear the financial burden of the potentially substantial
expenses which they may be forced to personally incur as a result of unforeseen circumstances or events beyond
DF’s reasonable control (as set forth in paragraph 7), and that they assume the risk and personal responsibility for
such expenses;
if fulfillment of the Dream involves travel or the gathering, participation In or exposure to large groups, they are fully
aware of the health and safety risks associated with such Dreams, including without limitation potential exposure to
infectious or communicable disease, impositions or quarantine, restrictions of movement and or travel advisories, the
threat of such risks, or the occurrence of any loss, damage cost or expense, including Losses, as a result.
Recipient has not previously been granted a Dream by DF or another charitable dream-granting organization; and
in requesting DF to fulfill the Dream, the Dream Recipient is not relying upon nor have they received any counsel or
advice from DF with respect to the advisability of or the risks attendant to the Dream.
10. Termination of Dream. Dream Foundation shall terminate the preparation and/or fulfillment of the Dream after the
signing of the Agreement, if: (1) Dream Foundation determines, after consulting with a medical professional, that
fulfillment of the Dream may endanger the health or safety of Recipient or of others involved in the Dream; (2) Dream
Foundation determines, after consulting with a medical professional, that the Recipient is or will be incapable of
appreciating or utilizing the goods, services, or activities related to the Dream; (3) the Recipient passes away prior to the
fulfillment of the Dream; (4) DF determines, in its sole and absolute discretion, that the Dream Recipient, his or her dream
or the participants of the Dream do not complement the values of the DF or those of its corporate partners; (5) Recipient
and any participants have breached any of the representations, warranties or covenants contained in this Agreement, or
(6) the Dream is in violation of the rules, policies or procedures of Dream Foundation or its corporate partners, in effect
from time to time. In the event DF aborts preparation or fulfillment of the Dream, Recipient, and all participants agree
that DF shall not be held liable or responsible for any expenses that Recipient, or any participants may have incurred in
contemplation of DF’s fulfilling the Dream. NOTE: Only Dream Foundation may make a request for resources on behalf
of a Dream. If the Dream Recipient, any participants, friends or anyone having knowledge of this Dream uses the name
of Dream Foundation to solicit support, the Dream will be immediately disqualified and terminated.
11. Further assurances. Recipient, and all participants agree that he or she shall, at the request of DF, execute and deliver to
DF all further documents that DF deems necessary or appropriate in order to prepare, execute and fulfill the Dream,
including without limitation, evidence of permission to perform a background check on the Recipient.
12. Counterparts. This Agreement may be executed in counterparts, any of which shall be deemed to be an original.
13. Amendment. This Agreement shall not be modified or superseded, except by a writing executed by the parties.
14. Governing law. The laws of the state of California shall govern this Agreement without regard to its conflict of laws
15. Binding effect. This Agreement is binding on all heirs, successors, representatives, and assigns of all parties hereto.
16. Severability. If any portion of this Agreement shall be determined to be invalid or unenforceable, all other portions shall
remain valid and enforceable.
17. Entire agreement. This Agreement, the application and all materials provided in support of the application constitutes
the entire Agreement and understanding of the parties with respect to the transaction contemplated hereby, and
supersedes all prior agreements, arrangements and understandings related to the subject matter. No representation,
promise, inducement or statement of intention has been made by any of the parties hereto not embodied in this
Agreement and no party shall be bound by or liable for any alleged representation, promise, inducement or statements
of intention not set forth or referred to herein.
18. Captions. The Captions appearing in this Agreement are for convenience and ease of reference only. They in no way
describe, limit or extend this Agreement or any of its provisions.
19. Proof of financial hardship. Dream Recipient understands DF reserves the right to request documentation of financial
The Dream Recipient and Participants hereby irrevocably authorize DF: (a) to publicize and use Participants’ likenesses,
voices and features, with or without their names, for any publication, promotion, advertisement, trade, business use, or any
other purpose whatsoever in perpetuity; (b) to photograph, videotape, film, and record each participant in any manner the
Dream Foundation chooses; (c) to copyright, convey, transmit or otherwise distribute, now or in the future, any such material
involving the participants for any purpose to anyone, including the general public, through all media presently in existence
or later invented, throughout the world, including without limitation print, video, television, radio, digital, internet, and social
media; (d) to publicize, now or in the future, the names of the participants including information regarding them, their
physical or emotional conditions and the details of any Dream granted.
The Dream Recipient and each of the participants agrees that it is not necessary for DF or anyone else to contact them prior
to releasing any information authorized by this document. Each of the Participants hereby releases DF from all liability,
damages, or claims of any kind resulting in or from, or arising from the use, distribution or disclosure of any photographs,
films, videotapes, electronic recording or other information regarding Participants and the Dream.
Initial here: (Must be initialed by ALL Participants)
By signing below, you affirm and acknowledge that you have read this Agreement, have retained a copy, and fully
understand and agree to its provisions. All Participants must sign Agreement. For any minor Participants, the signature
of their parent or guardian is both on behalf of the parent or guardian and on behalf of the minor.
Dream Recipient
Dream Participant
Dream Participant
Dream Participant
Dream Participant
Dream Participant
Dream Participant
Frequently Asked Questions
Dream Foundation grants final Dreams for adults with a life-threatening illness. With our headquarters located in
Santa Barbara, and a network of volunteers and supporters, we serve those in the greatest need around the country.
We receive no state or federal funding, relying instead on the generosity of our supporters to fulfill Dream requests.
What is a Dream?
Dream must come from the adult diagnosed with a terminal or life limiting illness.
Dream applicant must be able to communicate the Dream and comprehend/participate in the Dream
Dreams can be small (a dinner out with the family, a computer), elaborate (vacation at the Orlando theme
parks, travel to the Grand Canyon), or improve the quality of life (TV, laptop).
For more examples, please visit our website
We do not cover funeral expenses or posthumous requests.
Please also read what Dreams we are unable to grant on the cover page of the application.
Do I need to be a Hospice patient to receive a Dream?
No. We have a Hospice Application for hospice patients, and a General Application for patients still pursuing
active treatment.
Does it matter where I live in order to get a Dream fulfilled?
You have to live within the contiguous United States, Hawaii or Alaska.
You don’t have to be a US citizen, but need to currently reside in the US.
Filling out the application:
Anyone can fill out the application, but the Dream applicant (or if the applicant is unable to sign, his power
of attorney) has to sign it. We need to make sure that this is the patient’s Dream, not someone else’s for
the patient.
Anyone can write the Dream letter, as long as it reflects the applicant’s Dream.
The applicant has to be able to communicate his/her Dream, so if a patient is unconscious or unresponsive,
we are not able to help.
If you had a wish through Make-A-Wish Foundation as a child, we need to know when that was and what
your wish was, in order to determine your eligibility at this time.
If your doctor does not want to put down a life expectancy, send the application in anyway. As long as the
diagnosis and physician’s signature is there, we will try to work with your doctor to find out if you qualify for
our program or not.
Should you get denied based on the life expectancy that your doctor put on the application, feel free to have
the doctor fill out Step 4 again at a later time. We will keep your application for a year and would only need
the medical part resubmitted within that time frame.
If you don’t want to know what life expectancy the doctor puts in Step 4, Medical Information, feel free to
have the doctor mail or fax that page in separately. Please call us for our fax number, should you wish to
do that.
The original application has to be mailed to Dream Foundation, 1528 Chapala St., Suite 304, Santa Barbara,
CA 93101.
We do accept faxed applications for emergencies only. Should the patient’s life expectancy only be from a
few days to two months, you can call our office for the fax number to send the application in that way. We do
still need the original mailed in; so don’t forget to put that in the mail after faxing.
What should I include in my application letter?
We want to learn about you, your Dream, and the loved ones around you that it may affect. The more detail
you can offer, the better. We want to know why your Dream is important and unique to you. Help us
understand how this final Dream would make an impact for you and/or those you love.
How long does it take until I get my Dream?
It takes about three weeks to get the application processed before we begin with the verification process.
Verification will take anywhere from a few days to several months, depending on the response time of your
medical team/doctor.
Once we start working on the Dream, please allow about three weeks to arrange for air travel, as flights get
more expensive the closer to the desired date they are booked.
Emergency Dream requests get processed the day we receive them and are verified ASAP
While we will do our best to start working on your Dream as soon as possible, we cannot rush your request
for reasons other than medical necessity.
I do not file taxes, can I still apply? What’s the income limit to qualify?
If you don’t file taxes, just let us know about it and if you can, include an SSI, disability statement or a bank
We want to help those in the greatest of need that are unable to do so on their own. We look at each
application individually. We look at the taxable income, take into consideration how many people live in the
household, geographic location, and also check if the letter talks about financial hardship. Also, if someone
wants to meet a celebrity, then lack of financial means may not be the issue, but instead assistance in making
that connection.
What do I need to be able to travel?
If your Dream request requires travel, you need a major credit card or debit card with enough funds to cover
expenses such as meals and ground transportation, as well as the unforeseen cost associated with a hospital
stay and getting home in case of an emergency.
We do not ask for your credit card number.
If your Dream request includes a hotel stay, you will need a credit card at check-in to cover incidentals. If
using a debit card for hotel check in please be aware that a hold will be put on the card from the hotel. Often,
the blocked funds will not be released until about a week after your stay.
You need a valid government issued picture ID.
Your doctor needs to approve your travel. We will fax additional paperwork to your doctor to best assess
your medical needs and make sure that you are cleared for travel.
What is included in a travel Dream?
Typically, we cover air transportation (economy class only) as well as accommodations (one hotel
room/family room only).
Park passes.
We provide travel within the USA, Hawaii, and Alaska based on your location and at our discretion.
On a case-by-case basis, we may allow one-way travel to countries outside of the U.S. for patients who wish
to die at home and consider travel to U.S. territories.
Who can be part of my Dream?
The Dream will be for the Dream applicant, one other adult as a caregiver, as well as your children under 18
that live in your home.
An additional caregiver will be accommodated at the doctor’s request for medical reasons only.
Caregiver does not have to be a family member.
Additional people would be responsible for their own trip planning/cost.
If I want to visit family or have family sent to visit me, how long can I/they stay and how many
family members can be included?
As long as you can stay with family or family can stay with you, there is no time limit.
If you or your family need hotel accommodations, we can only cover 3-4 nights and one hotel room only.
If we bring family to you, we will be able to cover 2-3 tickets if they are flying, or gas money for one vehicle.
If you go to visit family, we will include you, your caregiver and your children under 18 who live with you.
What if I have special medical needs?
We are unable to assist with medical needs, such as ambulance transportation, oxygen, medical equipment,
nurses and aides, dialysis, etc…
We are unable to arrange or provide hospice care away from home, dialysis treatments, or arrange for your
oxygen needs.
Should you have a medical emergency during your Dream, we are unable to assist in any way.
What if I want dentures?
We will do our best to find a dentist that will work with us to provide dentures for you. However, we will only
be able to help if there are no teeth left, as pulling teeth is considered a medical procedure.
What if I want to meet a celebrity?
Celebrities are hard to reach, and they are very busy people. For that reason, it can take many months to
arrange for a meet and greet.
Celebrities do not make house calls, so you have to be able to travel to the concert/event that the celebrity
is at in order to meet her/him and still meet our travel requirements (see above)
In order for a meet and greet to be a good experience for both sides, we ask that if you apply to meet a
celebrity, you are able to communicate with him/her.
Before beginning a celebrity Dream request, we will have a trained volunteer meet you so that we may learn
more about you and why meeting this celebrity is so important to you.
What is an emergency Dream?
If the life expectancy of the applicant is two months or less, we consider the dream to be an emergency.
These requests can be faxed in, but the original still needs to be mailed. Please call us for our fax number.
Emergency Dreams get processed the day we receive them and are verified ASAP
If an emergency Dream is for a bedside reunion or similar, our turnaround time can be within 24 to 48 hours.
Emergency Dreams cannot be celebrity Dreams.
If an emergency Dream requires travel by the applicant, we will consider a road trip within limited boundaries
Please keep in mindDream Foundation reserves the right to its sole and absolute discretion to
cancel/change preparation or fulfillment of the Dream at any time after signing the Agreement if the
organization feels the Dream will endanger the health or safety of the recipient. Therefore, we ask that all
Dreams be realistic for the recipient and for Dream Foundation to fulfill.