Wish Application

Gifted Wishes Application

Please use our Online Funds Application and Liability & Authorization Form to submit your application. Simply fill in the information as requested and complete your e-signature at the bottom. As you move through the process there are (?)'s at many of the boxes which contain information to help you fill out the form if you need further information.

Online Funds Application

* Indicates required field

Hospice representative requesting the Wish: *

Hospice name, address and phone number: *

Email address of hospice representative: *

Contact Phone Number *

Amount of Wish request: *

Name and address of the person receiving The Gifted Wish: (This information is required by the IRS and is customarily asked by any type of 'wish' granting organizations.) *

Age of wish recipient: *

If you are requesting funds, please choose how you want them delivered: *

If funds are to be sent by check, please state who the check is to be made out to: *

Share the patient's wish with us. This is required for funding. Provide Amazon links for specific items. *

PLEASE NOTE:
Please remit receipts to Gifted Wishes at the conclusion of the Gifted Wish for our records as per the laws that govern a 501(c)(3). Thank you for your cooperation.

Gifted Wishes
6663 SW Beaverton Hillsdale Hwy. #63
Portland, Or. 97225

Liability release and authorization: Financial Agreement, Medical Information and Publicity

The undersigned have requested that the Pacific NW Hospice Foundation/Gifted Wishes, their respective volunteers, officers, directors, employees, and agents (collectively known as “PNW Hospice Foundation/Gifted Wishes”), fulfill a Gifted Wish for: *

The Wish Recipient and/or following people (collectively, “Participants”) have requested that Gifted Wishes/PNW Hospice Foundation financially assist them in participating in a Gifted Wish: *

Participants and/or the person(s) representing the Wish recipient are signing this Liability Release and Authorization: Financial Agreement, Medical Information, and Publicity (“Release and Authorization”) to bind themselves, their minor children, their heirs, successors, assigns and estates to the conditions described herein. Participants understand that involvement in the Gifted Wish may entail the risk of injury or harm to the Participants and agree that this risk is fully assumed by the Participants. In addition, and in consideration of Gifted Wishes/PNW Hospice Foundation considering the Gifted Wish and, if it so determines, granting the Gifted Wish, the Participants hereby release and agree to hold Gifted Wishes/PNW Hospice Foundation harmless for, from and against any and all liability, damages and claims (“Claims”) of any kind, known and unknown, which may be connected with, result from, or arise out of the consideration, preparation, fulfillment or participation in the Gifted Wish. This includes, but is not limited to, claims involving economic loss, illness or medical condition, accidental injury or death. Further, in specific regards to the monies supplied by PNW Hospice Foundation, any amounts exceeding the Requested Funds Amount for the Gifted Wish which has been agreed up by PNW Hospice Foundation/Gifted Wishes to become the sole responsibility of the Wish Recipient, the Participants or the person(s) making the Gifted Wish request. The Wish Recipient, or person(s) requesting the Gifted Wish, grants PNW Hospice Foundation/Gifted Wishes permission to obtain medical information necessary for consideration or fulfillment of the Gifted Wish. The Wish Recipient or person(s) requesting the Gifted Wish understand and agree that fulfillment of the Wish may result in publicity, whether or not PNW Hospice Foundation/Gifted Wishes actively takes steps to publicize the Gifted Wish. However, to the extent PNW Hospice Foundation/Gifted Wishes has control over the matter, Wish Recipient or person(s) requesting the Gifted Wish are agreeing to the following and by signing this Release and Authorization, all other Participants agree to be bound by this Publicity Agreement. PNW Hospice Foundation/Gifted Wishes is authorized to publicize the Gifted Wish and to use Participants’ likenesses, and other information about Participants and the Gifted Wish (including Wish Recipients medical condition), whether embodied in photographs, videotapes, recordings or any other format (collectively, “Information”), for purposes of promotion, publication, commercial advertising, or any other purpose whatsoever, now or at any time in the future. Wish Recipient and Participants understand and agree that PNW Hospice Foundation/Gifted Wishes may use any such Information: (1) in all manner and media whatsoever, whether now known or hereafter invented, including electronic and print media and the Internet; (2) without Participants’ full names full names; (3) without the payment of royalties or other compensation to anyone; and (4) without the need to notify them or to seek further approval before doing so. Wish Recipient, Participants and/or the person(s) requesting the Gifted Wish acknowledge reading and understanding this Release and Authorization. Wish Recipient, Participants or the person(s) requesting the Gifted Wish agree that this Release and Authorization fully and accurately express their understanding and has not been modified orally or in writing. By selecting the box below, the Wish Recipient and/or the person(s) requesting the wish hereby agree to the terms stated. *

Please complete your e-signature by typing your name in the box provided. This is your agreement to terms above. *

Submit

If you would like to print and mail the signed Liability and Authorization form and your Funds Application, please download each form by clicking on the respective buttons below.

You can mail your forms to:
Gifted Wishes
6663 Beaverton Hillsdale Hwy #63
Portland, OR 97225

Liability Statement

FUNDS APPLICATION