Magical Memories for Special Kids


Agency or Organization Application

Agency or Organization Information:

Name of Agency or Organization: *
Full Name: *
Rep Cell Number: *
Agency or Organization Number: *
Rep Home Number: *
Email: *

Note: You must provide contact information that is valid between now and the flight date. If your agency closes for the summer - our DTF Directors still need to contact you! Do NOT provide contact information that may not be valid during certain times of the year - specifically for school applications.

Address of Agency or Organization:

Complete Address:
Agency or Oganization Mission Statement: *

Additional Information:

Is there any reason that a nominated child or children from you agency or organization CANNOT be mixed with all the other children - by age & gender?
If "YES" please explain:
Is an agency or organization rep required to accompany any of your nominated children for the flight? *
If "YES" please explain :
Additional Comments:

Agency / Organization Acknowledgements:

1. As the Agency or Organization rep, I have read and fully understand the requirements as noted in the "Children" Tab on the DTF Website: *
2. As the Agency or Organization Rep, we will be fully responsible for compliance of DTF Child nominations and the agency may be responsible for FULL expenses of the trip, reimburesed to DTF, if found in non-compliance. Non-compliance could also result in denial of future applications: *
3. As the Agency or Organization Rep, I fully understand all nominated children for the flight will require a valid CANADIAN long form birth certificate, at the agencies expense. Some governmental aid may be available: *
4. As the Agency or Organization Rep, We fully understand the children we select for the DTF Program are usually segregated, by age & gender: *
5. The Agency or Organization acknowledges that this a 100% non-smoking and NO cell phone day: *
6. The Agency or Organization acknowledges that if the Agency Rep information changes, it is the sole responsibility of the Agency or Organization to notify Dreams Take Flight: *
7. As the Agency or Organization Rep, I understand that my Agency or Organization will be required to participate in DTFE's annual raffle ticket fundraiser. *
Date of Application Submitted (DD/MM/YR): *

Dreams Take Flight Edmonton - By submitting this form, your Agency or Organization has agreed to all the terms on the Children tab on our DTF Edmonton Website. Also all the information submitted in this form can be used by the Directors of DTF Edmonton. As always, privacy is very important to us, no information is ever shared or given to any outside agencies.

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