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Title

Parent/Carers First Name*

Parent/Carers Surname*

Primary Language

Contact Telephone Number*

Email Address*

Address line 1*

Address line 2

City*

Postcode*

Which family member is chronically ill? (please briefly describe their illness here)

Child 1 - Name and Age*

Child 2 - Name and Age

Child 3 - Name and Age

If you have more than three children please add additional information below

Now for the important bit! Please outline below the details of your child/children's wish request

Please submit a photo of your child/children. This may be used to promote the wish in order to make it happen (i.e. fundraising)

I confirm that I am the legal parent/guardian of the named child/children and wish to apply for a Grant a Smile Children's wish

I confirm that I read the Consent Form

LIABILITY RELEASE AND GUIDELINES

Parent/Carers Name (required)

Email (required)

Child/children's Name

i) I/we hereby agree that Grant-a-Smile, a UK not-for-profit charity, can grant the agreed wish of the child/children named above. I/we confirm that I/we are the sole legal guardians(s) of the above named child/children.

ii) External communication (such as Grant-a-Smile website publicity) will be required to help fulfil the wish. Information could include, but is not limited to, problems encountered with transportation, food, lodging, medical problems, (physical and emotional), entertainment, photographs and accidental injury of any kind.

iii) I/we agree on behalf of ourselves and the above named child/children, that Grant-a-Smile, its agents, volunteers, directors, and employees shall remain free from all liability connected with granting the wish.

iv) I/we hereby grant permission for Grant-a-Smile, to obtain and communicate information regarding the chronic conditions concerning the parent when appealing for support in granting the child/children’s wish.

We further authorise all such physician(s) to release relevant medical information to Grant-a-Smile regarding the above named Parent for the purpose of granting the wish.

The name and address of all such physician(s) are set below:

GP Practice

Doctor's Name

GP Practice Address

Postcode

v) I/we confirm that neither Grant-a-Smile nor any agent, director, officer, volunteer or employee of Grant-a-Smile, nor any other person associated with said organisation, has given us any advice or counsel with respect to any risk associated with said wish.

vi) I/we agree that Grant-a-Smile is acting at our request and in accordance with our instructions.

vii) I/we indemnify Grant-a-Smile and its agents, volunteer, directors and employees from any liability, cost or expense (including legal fees) arising out of any misrepresentation made by us or any breaches of agreements.

viii) I/we have read and agree with that the attached release is accurate.

ix) I/we understand that only above said child/children and undersigned parent/guardians will be entitled to benefit from said wish.

You must tick this checkbox to agree to the above (required)
I am the parent/carer of the above named child/children and have read/agreed to the above mentioned liabilty release.

Name (required)

Date (dd/mm/yyyy) (required)

GRANT-A-SMILE PUBLICITY AGREEMENT

We represent that we have read the above release, prior to its execution, and that we understand and intend to be bound by the contents thereof.

I/We, the “parent/guardian(s)” of the “Child/Children” give our consent for representatives of Grant-a-Smile to use our Child/children’s name and/or picture for the purposes of raising funds to grant his/her wish request.

I/we give our consent for Grant-a-Smile to contact television, radio and newspaper media to publicise stories about our child/children’s wish for the purpose of increasing public awareness of Grant-a-Smile UK and their fundraising needs.

I/we understand that all such stories will be done tastefully and will portray with dignity the Parent's condition and our family's situation.

I/we agree not to initiate contact with news media regarding our child/children’s wish unless we have first notified Grant-a-Smile. If we do contact media sources without notifying Grant-a-Smile, I/we understand that this action may be detrimental to the arrangements being made to grant our child/children’s wish.

I/we understand that our willingness to allow our child/children’s name and picture to be used for publicity may help to facilitate the arrangements for our child/children’s wish. However, our refusal to participate in Grant-a-Smile publicity campaign may determine whether Grant-a-Smile decides to grant our child/children’s wish.

Parent/Guardian's Name (required)

Wish Applicants Child's Name (required)

Additional Children

I am the parent/carer of the above named child/children and I agree to the above mentioned Publicity release.

GRANT-A-SMILE WISH GUIDELINES

i.) Wishes are granted by Grant-a-Smile UK to a child/children (“Wish Child”) without regard to race, national origin, ethnic background, sex, religion or handicap.

ii.) The Wish Child must be eighteen years of age or under when the application is received.

iii.) The Wish Child parent must verify that they have a life-threatening illness. Parent/guardian’s must provide a doctor’s report when submitting the application.

iv.) Only one wish may be granted per family. Grant-a-Smile does not grant wishes to a child/children who has previously received a wish from Grant-a-Smile.

v.) An applicant may list up to three potential wishes on the application.

vi.) No additions to a wish request may be made once Grant-a-Smile has processed the application.

vii.) A Wish Child who desires to meet or speak to a celebrity is hereby advised that the celebrity’s schedule and willingness to meet the Wish Child determines this request. Celebrities are often overwhelmed with such requests. The following procedures are involved to grant the wish: 1. Locate the agent. 2. Agent confirms that the parent has a life-threatening illness. 3. Locate celebrity. 4. Obtain agreement with celebrity to meet Wish Child. (This can take 1-2 years). 5. Finalise appropriate date, time and place for meeting. This usually happens at the last minute. Flexibility is a MUST!

viii.) Families are advised that Grant-a-Smile UK cannot put a timeframe on the granting of a wish due to factors such as available funds and/or other necessary resources. Grant-a-Smile has no obligation to consider applications in the order in which they are received.

ix.) Misinformation or forgery in any of the documents submitted to Grant-a-Smile will lead to a cancellation of the wish.

x.) Grant-a-Smile is not responsible for the repair or maintenance costs of items that the child/children has received upon the granting of a wish.

xi.) If the Wish Child's parents wish to accompany their child to their wish destination, they must arrange doctor’s permission and request special arrangements. i.e.: medical equipment, presence of medical staff, etc.

xii.) Trips will ordinarily be scheduled for five days and four nights. If funding permits, and Grant-a-Smile determines that the circumstances are justifiable, a trip may be extended by Grant-a-Smile Kids to seven days.

xiii.) Grant-a-Smile will be unable to pay medical bills or provide funds for emergency assistance.

I/we hereby confirm that I/we have read, understood and agree to these Guidelines, and that the information in the attached Wish Application is true and correct.

Parent/Guardians Name (required)

Todays Date (required)

I confirm that I read theWish Agreement and Guidelines

Parent/Carers Name (required)*

Email (required)*

Child/childrens's Name/s

By submitting this form, I understand that information discussed with me will be stored and used for the purpose of providing services to me and my family. I agree that the information and photographs stored can be shared via Grant-A-Smile platforms in order to communicate case studies to other families who will benefit from these services.

Privacy Notice:

Grant-a-Smile and partner organisations will be sharing relevant personal information with each other. This is so we can co-ordinate work to maximise the support for each family. Where a Grant-a-Smile volunteer is unavailable, we would endeavour to assign you a local cleaning company at no cost to you.

All Smile Heroes/Volunteers and local business cleaning company staff will hold a valid DBS check for your peace of mind. Upon arrival, they will show you their national ID card for verification.

Please note that all information will be processed strictly in accordance with the Data Protection Act 1998 and other relevant legislation. Information will be held in confidence with partners of Grant-A-Smile. You have the right to request a copy of any information that the Grant-a-Smile holds about you.

I confirm that I read theWish Application Form