WISH APPLICATION FORM

WAY respects your privacy and personal information collected on this form will only be used for the purpose(s) indicated on the form. Access to the personal information will be limited to those who require it for program or administrative purposes. Requests for access to information about yourself in the custody or control of WAY may be directed to info@weareyoung.ca. Any privacy inquiries or concerns regarding personal information collected, used, or disclosed by WAY or requests for a copy of our Privacy Policy, may be directed to info@weareyoung.ca.

* Please note: For a wish application to be accepted, wish applicants must be 70 years of age and living within Nova Scotia, Canada.

Wish Eligibility:

Is the nominated applicant 70 years of age or older and a permanent resident of Nova Scotia, Canada? *
YesNo

Wish Nominator's Contact Information:

First and Last Name:

Address:

Phone Number:

Email:

Preferred Method of Contact
EmailTelephone

What is your relationship to the applicant?

Applicant (Elder) Information:

First and Last Name: *

Date of Birth: *

Address: *

Phone Number: *

Email:

Preferred Method of Contact
EmailTelephone

How did you hear about We Are Young? *

Please specify. *

In as much detail as possible, please describe the Wish:*

What inspired you to submit this wish on behalf of the nominated?*

What is it about this Wish that makes it meaningful to the Nominated?*

When did the Nominated realize they wanted this Wish? What prompted this Wish?*

Has the Nominated experienced this Wish previously? If so, please indicate when and why it would be meaningful to do so again.*

For what reason has the Nominated not be able to fulfill the Wish on their own? If the Nominated has desired this Wish for a long time, why were they not able to fulfill the Wish on their own? This may include family commitments, financial constraints, etc.*

In as much detail as possible, please describe how WAY may help facilitate this Wish.*

Are there any physical or mental infirmities that will need to be accommodated for the Nominated to fully experience this Wish? If so, please list them.*Please note that WAY makes every effort to accommodate all impairments when planning wishes. *

Many Elders experience adverse conditions or symptoms attributable to their age, such as such as social isolation, loneliness, physical or mental disability, poverty, decline in motor skills, flexibility, strength, speed of execution, or hand-eye coordination, among others. Please describe any adverse conditions or symptoms attributable to their age the Nominated is experiencing.*

How will granting this Wish positively benefit the life of the Nominated? How will granting this Wish address or alleviate the adverse conditions or symptoms described in Question 7 (above) in a lasting and durable way?*

How would granting this Wish inspire others and help WAY attain their goal to improve their goal to create age-friendly communities and address or alleviate adverse conditions or symptoms attributable to aging experienced by Elders across Canada?*

Has the nominated applicant ever been convicted of a crime for which they have not received a pardon?*

By submitting this Wish, I acknowledge the acceptance of this application by We Are Young Association does not constitute a commitment by We Are Young Association to fulfill my wish request. If We Are Young Association determines that this wish should enter the next stage of the wish process, a We Are Young Association representative will contact me for more information. I understand that this contact also does not constitute a commitment to grant my wish. Furthermore, I certify that I meet all qualifications for eligibility, and declare that all of the information given by me in this application is true to the best of my knowledge, and I agree to inform We Are Young Association in a timely manner should any information provided in this application change.