Magical Memories for Special Kids
edmonton

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Child Info

Agency Rep:

Please take a few minutes and fill out all the information required for each child you are nominating for this year's flight.

You MUST fill out one form for each child on the flight. After you have completed the form, please ensure that you hit the "Submit" button. If your form has been submitted without missing information or errors, you will receive the link for the two mandatory consent forms. Please print these out, get them signed, and submit to lgatti@dreamstakeflight.ca. Please maintain the originals, which must be handed in no later than September 10, 2018.

Thank you for helping make the magic for your child on this year's flight.

Nominating Agency:
Date Submitted:
Name of nominated CHILD:*
Is this child an ALTERNATE?

AGENCY CONTACT INFORMATION

Name of Agency Contact:*
Agency Address:*
Office Phone:
-
Emergency Cell:
-
Agency E-mail:

CHILD SELECTION CRITERIA

The child is between the age of 8 & 13 years old at the time of the flight:*
If NO what age is the child:
The child's family is in a financial situation that would not allow for trip of this nature on their own:*
Has this child ever been on an airplane:*
Confirmed this child has NEVER been to a Disney Theme park:*
The child is a Canadian citizen:*
The child has a Canadian Birth Certificate or Canadian Passport:*
The child is physically, mentally or socially challenged:*
It is understood the child MUST be cleared as per the medical criteria of the DTF medical team:*

If the child meets the above basic criteria, please proceed to the nomination documents that follow.

CHILD INFORMATION

Legal FIRST Name (as it appears on the Birth Certificate)*
Legal LAST Name (as it appears on the Birth Certificate)*
Preferred FIRST Name
Date of Birth:*
Age (on day of flight)*
Gender*

CHILD TRAVEL DOCUMENT INFORMATION

Birth Certificate:

Birth Certificate Registration #*
Issuing Province/Territory*
Upload scanned copy of Birth Certificate*

Canadian Passport (if applicable):

Passport Number
Place of Issue
Nationality
Date of Expiry:
 / 
 / 

Provincial Medical Card #

Health Card Number*
Province/Territory*

CHILDPARTICULARS

Eye Colour:
Hair Colour:
Height (in centimeters):
Weight (in kilograms):
Birth marks or scars etc:
Wear Glasses:*

Child Clothing and Shoe Sizes

T-shirt Size:*
Pants:*
Shorts:*
Jacket:*
Hoodie Size:*

PARENT OR LEGAL GUARDIAN INFORMATION:

Status to child:*
Is there a custodial agreement between the parents that require both approvals for travel:*
If YES, please stipulate:
Parent/Guardian Name:*
Address of Parent or Guardian:*
Does the child live at the above address also?*
If the answer is no, please provide the address the child lives at:

Parent/Guardian Contact Information:

Home Phone:
-
Cell Phone:
-
Work Phone:
-
Parent/Guardian E-mail:

Emergency/Alternate Contact Information:

Name of Emergency Contact:*
Relationship to Child:
Emergency Contact Home Phone:
-
Emergency Contact Cell Phone:
-
Emergency Contact Work Phone:
-

*Very Important: if any of the above contact information changes from now until the day of flight, it is the parent or guardian's responsibility to keep the agency updated. Failure to do so could result in the removal of the child from the flight!

CHILD MEDICAL DECLARATION:

Does the Child have a pre-existing medical condition?*
If YES, does the child have medical coverage which covers travel to the USA?
If YES to either of the above please provide details:
Does the Child have any allergies?*
If YES, explain
Does the Child have any special dietary requirements?*
If YES, please detail:
Does the Child have any special needs (include behavioural or phobias)?*
If YES, please explain:
Is the Child taking any medication?*
If YES, please provide name, does, frequency, and time:
Does the Child require a wheelchair?*

CHILD INSURANCE DECLARATION:

Has your child ever required or received medical treatment or prescription medications for heart / cardiovascular condition or a stroke / cerebral vascular condition or an aneurysm?*
In the past 12 months (6 months for high blood pressure) has your child received any new prescription medication or new medical treatment for any medical condition?*
In the past 12 months (6 months for high blood pressure) has your child had any prescription medication changed, reduced, stopped or increased for any medical condition? (not including a change between brand name & generic brand)*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had lung/respiratory condition?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had diabetes which is controlled by diet, medication, or with insulin?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had any test, investigation, or surgery recommended but not yet completed?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Cancer or Leukemia?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had blood disorder?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Kidney disorder requiring dialysis or Liver disorder?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Circulatory disorder of the arteries or veins?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Pancreatic disorder?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Muscle, Bone, Joint disorder (not arthritis)?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Stomach or Bowel disorder?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Urinary disorder?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Parkinson's disease or Seizures?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had High Blood Pressure (Hypertension)?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Prostate disorder?*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had any other pre-existing condition currently requiring medication?*
If you answered YES to any of the above, please provide more information:
Does your child require assistance to sit upright and walk?*
Does your child have problems with bowel or urinary functions?*
Does your child require supplemental oxygen?*
Does your child require a feeding tube?*
Does your child use any special devices which are required at all times?*
If you selected YES to any of the above, please provide more information:
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