Live-A-Dream Award

About AHCF & The Award

The Arizona Health Care Foundation was established to enhance the lives of our residents and the people who care for them. The Foundation wants to make dreams a reality for residents in long term care and assisted living centers throughout Arizona. The Live a Dream Award is a program that attempts to grant those wishes. Recipients are selected by the Arizona Health Care Foundation on the basis of our ability to fulfill the dream. Applications will be reviewed by the AHCF Board of Directors.

Live-A-Dream Criteria

Award recipients must be a resident in an Arizona Health Care Association member facility. The entire application must be completed for the nomination to be considered. Applications should be sent to: Arizona Health Care Foundation, Attention Live-A-Dream, 3003 N Central Ave, Suite 860, Phoenix, Arizona 85012. For additional information or clarification call AHCF at (602) 265-5331 or email: [email protected].

"*" indicates required fields

Your Name:*

First Last

Your Title:*

Your Email:*

Name of Nominee:*

First Last

Facility:*

Address:*

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Phone:*

Fax:

Email:*

1. Describe the wish of the nominee.*

2. In 350 characters or less, explain your reasons for nominating this person.*

3. Why has the nominee been unable to accomplish this on his or her own?*

4. Will facility staff be needed to assist in fulfilling this wish? If so, who and why?*

5. Is there any additional information regarding the physical/cognitive condition or other details that would impact the possibility of fulfilling the wish?

6. What is the projected cost of the wish?

7. If awarded, to whom should the check be made out?

Photos

Do all parties involved consent to the publishing of any media submitted?*

Yes

No

Do you have photos to upload?*

Yes

No

Please upload up to 4 images:

Drop files here or Select files

Accepted file types: jpg, jpeg, pdf, Max. file size: 5 MB, Max. files: 4.

Photograph Release Statement*

I, do hereby authorize the Arizona Health Care Association full use of the photograph(s) submitted. This photograph(s) may be used either in conjunction with or without using my name. I realize that the control of the photographic materials are my responsibility and I absolve the Arizona Health Care Association of any liability connected to the photographing or distribution of said materials. I do further certify that I am of full age and legal capacity to execute the foregoing authority and release.

Please note that a medical release and a liability waiver will be requested prior to granting any wish.

Name of Administrator:*

First Last

Your Signature:*