Application Form

Wish Application Form

If you are nominating a senior for a wish, please remember that all questions refer to the senior you are nominating. Please be as thorough as possible to ensure your application is considered.

Note: Proof of age, income, personal history, physical condition from a physician's letter and legal alien or citizenship are conditions of this application and must be provided if requested for the wish to be granted.

Senior Contact Information

Nominator Information

Senior Contact Information

Title :
First :
Surname
Gender:
Street Address:
City:
State:
ZIP:
Phone Number:
Email :
Senior Living Community Name (if applicable):

Nomintator Information
Nominator Name :
Relationship to Applicant :
Street Address
City :
State :
ZIP :
Nominator Phone Number :
Nominator Email :

Additional Details

Wish description*

What makes this wish meaningful to you?*
Please be detailed in your response

What prompted this wish?*

Additional Details

When did you know or first realize you wanted this wish? *

Describe any mental, emotional, physical or spiritual benefits you will experience as a result of having this wish granted? *

What makes this wish meaningful to you?*
Please be detailed in your response

Why are you unable to fulfill this wish on your own? *

Have you done this before?*

If you are looking to reconnect with someone, when was the last time you saw them? (optional)

Are you a military veteran?*

Are you a legal resident or citizen of the U.S. or Legal Alien? *

Have you ever been convicted of a crime? *

Additional Details

Before we move forward with a wish, we would like to try and get to know you.
Please take the time to tell us a little bit about yourself.

Tell us a story about yourself, the things that make your smile, such as hobbies, interests, passions,
or people that interest you. If you were in the military, and any medals or honors you received.
Please be detailed in your response

By submitting this wish, I acknowledge that acceptance of this application Metta4Life dose not constitute a commitment by Metta4Life to fulfill my wish request. If Metta4Life determines that this wish should enter the next stage of the wish process, a Metta4Life representative will contact me for more information. I understand that this contact also dose 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 give by me in this application is true to the best of my knowledge, and I agree to inform Metta4life in a timely manner should any information provided in this application change.

Wish Application Form

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