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. *

Please describe the wish and why it is meaningful: *

What inspired you to submit this wish? *

When did the nominated applicant realize they wanted this wish? What prompted this wish? *

Has the nominated applicant ever had the opportunity to experience this wish in the past? If so, please indicate when and why it is meaningful to experience it again. *

What barriers are preventing this wish from being granted already? *

If the nominated applicant is looking to reconnect with someone, when was the last time they saw them? *

How will the granting of this wish impact the nominated applicant? *

Are there any physical or cognitive impairments that will affect the ability of the nominated applicant to participate and/or experience this wish? *Please note that WAY makes every effort to accommodate all impairments when planning wishes. *

How can WAY help grant this wish, either in full or by providing partial support? *

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

Is there anything else you would like to tell us or anything that may aid us in helping grant this wish? *

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.