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AN ELDERLY WISH FOUNDATION A Non-Profit Organization "Making Final Wishes Come True" Dear Wish Applicant, All of us at An Elderly Wish Foundation are proud to offer you hope during this difficult time. We believe that every human being, 60 years or older, deserves to ask for a special wish. An Elderly Wish Foundation is a non-profit organization which “makes wishes come true”, for the terminally ill elderly and those with life threatening diseases (e.g. Alzheimers, AIDs, Congestive Heart Disease (COPD), renal disease), in Contra Costa County. By working together, with people helping people, we look forward to granting your special wish. Once you have completed this form, mail it to us, and we will get started on your request. Sincerely, An Elderly Wish Foundation How to Request a Wish To help make your wish come true, we need a few things to get started. We ask that you take the following steps: Write a Wish Request Letter. Complete the Request Form. Have your physician or medical care provider complete the Physician Statement; Include a photo of yourself (optional). Once you have completed these four steps, send the packet to: An Elderly Wish Foundation P.O. Box 4365 Antioch, California 94531-4365 We will verify your eligibility, contact you with any questions, and get started on your wish. ************************************************************* Step 1: Wish Request Letter or Fax As part of your wish request, we ask that you send us a personal letter, written by you, or a close family member, describing your wish, why you need our help, and the importance or significance of the wish to you. We want you to tell us WHY this wish matters to you, and HOW this wish will provide you with a greater sense of comfort and fulfillment. Your letter or fax should: Refer to the illness you are battling; Clearly describe what your special wish is; If your wish involves air travel, include the number of participants, airport of departure and desired dates for travel; Unfortunately, we cannot grant the following types of wishes: Requests for cash, automobiles, or property; Requests for foreign travel or visas Requests to pay for medical treatments or legal assistance ************************************************************* Step 2: WISH REQUEST FORM Please write legibly in ink. Recipient’s Name ________________________________________ Address ________________________________________________ City ______________________ State _________ Zip ____________ Phone ( ___)_______________________ Email ____________________________ Age (60 & Over) _________ DOB _________________________ Referred by____________________________________________ I give permission to An Elderly Wish Foundation to contact my physician for verfication of my illness on behalf of my wish. Signature ____________________________ Date___________ Nearest Relative/Contact _________________________________ Relationship ___________________________________________ Address ______________________________________________ City ________________________ State ______ Zip ___________ Phone ( ___)__________________ Email ________________________________________________ ************************************************************* Step 3: Physician’s Statement of Eligibility I certify that I am the wish Recipient's Primary Physician or Medical Care. I give permission for a wish to be granted to the individual named below, by the Board of Directors of An Elderly Wish Foundation. I understand that to be eligible for a wish the recipient must have been diagnosed with a terminal or life threatening disease. Recipient’s Name ____________________________________ Diagnosis ___________________________________________ Is oxygen required for air travel? YES / NO Physician or Medical Care Provider’s Name: ______________________________________ Address _______________________________________________ City _____________________ State _______ Zip ___________ Phone ( ___)_________________ Email _________________________________________________ Signature _____________________________Date __________ ************************************************************* Step 4: Enclose a photograph ************************************************************* Send the completed application to: An Elderly Wish Foundation "Making Wishes Come True" P.O. Box 4365, Antioch, CA 94531-4365 Telephone (925) 978-1883 /=/ FAX (925) 978-1884 Website: elderlywish.org