Donnas Dream House Nomination Form

Nomination Form For A Child With A Serious Illness
Details of Nominated Poorly Child
Boy / Girl
Age
Child's Full Name:

First NameLast Name
Date of Birth

DayMonthYear
Nature of Illness
Please give details...
Date Diagnosed

DayMonthYear
Full name of Parent(s) or Guardian(s)
Parent(s) or Guardia(s) Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Telephone Number

Area CodePhone Number
Mobile Number
Format: 00000000000.
E-mail
Details of current medical treatment:
Name of Hospital where child is treated
What equipment will you bring with you? (e.g. Wheelchair / Oxygen etc. If you're using our hoist please bring your own custom sling )
Have the family received a free or subsidised holiday from DDH or any organisation?
Name of organisation
Please List Other People Who Will Stay With Your Child

* Name, Age and Relationship are required *
Guest 1 Name and Age
Guest 1 Relationship
Guest 2 Name and Age
Guest 2 Relationship
Guest 3 Name and Age
Guest 3 Relationship
Guest 4 Name and Age
Guest 4 Relationship
Guest 5 Name and Age
Guest 5 Relationship
Guest 6 Name and Age
Guest 6 Relationship
Please Specify Your Preferred Holday Dates

(We cannot guarantee availability)
Please add any additional information
Details of Person or Organisation nominating this child
Type of Nomination
Nominating Organisation Name
(If Applicable)
Nominator Full Name:

First NameLast Name
Address

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Telephone Number

Area CodePhone Number
Mobile Number
Format: 00000000000.
Email
example@example.com
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Signature
Personal Information Consent
Contact
Photography / Videography Consent
Photos, video or audio of our family may be taken during activities or events and used by Donna's Dream House or promotion, fundraising and awareness (including print, online and social media). No personal details will be shared without further permission. Media will be stored securely under UK GDPR, and consent can be withdrawn at any time by contacting Donnas Dream House
Take a look around Donna's Dream with our Virtual Tour
Visit our website

https://www.donnasdreamhouse.co.uk/

Make a donation

https://www.donnasdreamhouse.co.uk/donate.php

Social Media
Should be Empty:

Nomination Form For A Child With A Serious Illness

Details of Nominated Poorly Child

Nature of Illness

Full name of Parent(s) or Guardian(s)

Photography / Videography Consent

Take a look around Donna's Dream with our Virtual Tour