Wish Application

Paulie's Super Siblings Wish Application
Please fill out seperate forms for each child
CONTACT INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Childs Name your requesting wish for*

First NameLast Name
Birth Date*

MonthDayYear
Name of additional sibling/s

Health Information
In this section please fill in information about your child that has or had pediatric cancer
Childs Name*

First NameLast Name
Birth Date

MonthDayYear
Date of diagnosis*

MonthDayYear
Current Health Status *
Type of Cancer*
Stage of Cancer (if applicable)
Current Prognosis
IE: Great, Good, Fair, Terminal
Name of hospital where child has/is receiving treatment*
Hospital Address*
Child Life Specialist Name

Terms and Conditions

By agreeing to these terms and conditions you have read and understand the following:

This forms serves only as an application and does not guarantee that your child will be selected for a wish. All applications will be kept on file until the child reaches the age 18 or their wish has been granted. You may submit one application per child per year, but how often you submit an application does not increase your chances of being selected.

You may submit an application for all children 18 and younger. There is no time limit on how long after treatment is completed or child has passed to request a wish as long as the child you are requesting a wish for is under 18.
- All wish budgets are currently $1,500-$2,000 per child. The only time a wish may exceed that amount is if there is an additional outside sponsor or donations.
- We will do our best to provide your child with a wish they will never forget but some wishes may need to be downsized due to budget restrictions.
- If your childs wish is a trip you may not resell or give the trip away to anyone. If your family cannot attend the trip due to an emergency or travel restrictions PSS will do our best to adjust your trip arrangements for a future date.
- Each wish is different; some wishes can be granted in as little as a few weeks and others may take several months. We will do our best to complete the wish in a reasonable time frame that works best for your family.
- If you are requesting wishes for multiple siblings we do our best to grant them at the same time, unless otherwise discussed. Because of this, it may take longer for your childrens wishes to be accepted due to budget restrictions.
- Once the wish granting has started, and as long as no funds have been spent, you may postpone a wish granting. In the event of a wish being postponed your application will be placed back into a file for a later date.
- If the wish granting has started and funds have already been spent towards the wish we will do our best to make adjustments to the time frame, if requested, but we cannot guarantee adjustments can be made.
- We strongly urge against applying for wishes for children under the age of two years. We want the wish to be something they will remember for years to come and the younger the child the less likely they will remember. But you are allowed to request a wish for any child 0-18 years of age.
- A child is only eligible to receive one wish in their lifetime from PSS.
- Only a parent or legal guardian may submit a wish application. All applications submitted by anyone other than a parent or legal guardian will be rejected.
- During the wish granting process we may take suggestions from parents or guardians but ultimately this is a wish for the child. We will approve wishes with parents/guardians prior to making purchases.
- Once an application is submitted it will be reviewed by the board of directors. Then it will be determined if and when the wish can be granted.
- If your childs wish application is selected you will be given paperwork for your childs doctor or child life specialist to sign and fill out. Failure to complete this paperwork will result in an automatic wish denial. If your child has passed away you will still be required to provide information that verifies the childs illness or passing.
- When applying for a wish the child must have been alive during ill childs treatment/illness. Any children born after the passing of ill child will not qualify for a wish.
- Terms and conditions may change at any time.
- **The information that you have submitted in this application is true and accurate to the best of your knowledge. Any persons found to be attempting to defraud Paulies Super Siblings by providing false medical information will be held liable for repayment of the full wish, any travel/administrative expenses related to the wish, and any legal fees associated with reclaiming said funds. Paulies Super Siblings will also notify authorities of said defraudment.
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Health Information