Wi s h R eq ue st Ap p lica t io n
Dear Wish Applicant: The Sunset Wish Foundation is pleased to have this opportunity to offer you a ray of sunshine during a difficult time. Everyone deserves a chance for to have a memorable wish come true; and we do our best help those unable to produce them on their own. However, there is no guarantee. We can only attempt, within our resources and limitations, to provide an opportunity for closure and a sense of fulfillment by granting your special wish. Our 501(c)(3) charitable organization is based in Winston-Salem, North Carolina. We receive multiple requests across the country and we do our best to give immediate attention to each wish request. With everyone's help, we will try to help make your wish come true! We ask that you return the application within 2 weeks in the enclosed self addressed stamped envelope. Sincerely,

Karen M. Harrison

Andrea M. Layton

The Founders of the Sunset Wish Foundation

H E L P U S T O F UL F IL L Y O UR W I SH E L P S T O UL F IL L O UR ISH
Please read the following information very carefully. You must follow all instructions to complete the steps necessary for us to make your wish come true.
Incomplete applications are not accepted. Our volunteer staff is unable to complete the required documentation for you.

P..O.. Box 5703 P O Box 5703

Wiinstton--Sallem,, NC 27113 W ns on Sa em NC 27113

Phone:: ((336)) 978--WISH Phone 336 978 WISH

W is h R eq ue st Ap p l ica ti o n
S TEP I: F ILL O UT T HIS I NFORMATION
Recipient’s Name Age (must be over 18) Date of Birth

Address

Apt. No. / Suite

City, State, Zip

Contact Number

Cell / Work Number

Email

Annual Income

Referred By

Ethnicity (optional)

Primary Wish Request

Secondary Wish Request (if resources or other circumstances prohibit your primary request)

Name of Spouse, Nearest Relative or Other Contact Person

Relationship

Age

Address

Apt. No. / Suite

City, State, Zip

Contact Number

Cell / Work Number

Email

Wish Recipient’s Printed Name

Wish Recipient’s Signature

Date

P..O.. Box 5703 P O Box 5703

Wiinstton--Sallem,, NC 27113 W ns on Sa em NC 27113

Phone:: ((336)) 978--WISH Phone 336 978 WISH

S TEP II: S TATEMENT OF E LIGIBILITY
( TO BE FILLED OUT BY PHYSICIAN OR HOSPICE REPRESENTATIVE ONLY )
Physician or Hospice Representative’s Name Address Recipient’s Life Expectancy (months) Suite/Office No. City, State, Zip Currently Under Hospice Care?

Contact/Office Number

Fax Number

Email

Physician or Hospice Representative Signature

Date

By providing the above information and giving my signature, I certify that I am the treating physician or Hospice Representative of the individual (Wish Recipient Applicant) named above. The applicant is in possession of sound mental capability and able to sign legal documents. I have discussed the wish to be fulfilled by the Sunset Wish Foundation with the applicant and/or their family. I understand that to be eligible for a wish, the applicant must be in the last year of life.

S TEP III: L ETTER AND P HOTO
R EAD AND C OMPLETE THE FOLLOWING . W RITE A L ETTER DESCRIBING Y OUR W ISH AND I NCLUDE A PHOTO OF Y OURSELF .
Please write a personal letter written, or have a family member or a close friend do it for you, describing your primary wish and your alternate choice. Tell why you need the help of the Sunset Wish Foundation to fulfill your wish. Share why this wish is important to you and how it will bring closure and fulfillment to you. Your letter should: 1. Be one (1) page or less is length. 2. Include your diagnosis and the prognosis you have been given. 3. Clearly describe your wish, being as specific as possible. 4. Include names and ages of any immediate family members (those living in the same household) participating in your wish. Please be aware that the Sunset Wish Foundation cannot grant the following types of wishes: • NO requests for cash, automobiles, property or RV rentals; • NO requests for Visas or travel outside the United States • NO requests for cruises; • NO requests for someone with chronic illness who is not in the last year of life; • NO requests for surprise wishes; • NO requests for non-residents of the United States

□

Check here if you have ever been granted a wish by another wish granting organization.

P..O.. Box 5703 P O Box 5703

Wiinstton--Sallem,, NC 27113 W ns on Sa em NC 27113

Phone:: ((336)) 978--WISH Phone 336 978 WISH

S TEP IV: P UBLICITY RELEASE
T HE FOLLOWING INSTRUCTIONS ARE FOR THE PUBLICITY R ELEASE . PLEASE READ AND ANSWER CAREFULLY . If your wish is accepted, the Sunset Wish Foundation would like to share your story and/or photo with the public media, using one or more of the sources listed below. Please mark each box next to the media source that you agree the Sunset Wish Foundation can share the story of your wish fulfillment. It is most helpful to the Sunset Wish Foundation to allow us to use any or all of the options. This will permit the Foundation to help raise awareness and possible donations to assist in achieving your wish.

The Sunset Wish Foundation respects the privacy of wish Recipients. We will only use a wish recipient's first name when we share their story and /or photograph. Should your situation require further special privacy considerations, please explain this clearly to our Wish Fulfillment Staff when they contact you.

Please check the box next to all forms of acceptable publicity: € Local Radio, TV, Newspaper € State and National Radio, TV, Newspaper € The Sunset Wish Foundation Newsletter € The Sunset Wish Foundation Website € Direct mail from the Sunset Wish Foundation € All of the above

Please Note: If you checked any of the above items you will need to select and initial Option 1 on the enclosed Wish Fulfillment Agreement.

€ Please do not use my story and/or photo in any of the above media.

P..O.. Box 5703 P O Box 5703

Wiinstton--Sallem,, NC 27113 W ns on Sa em NC 27113

Phone:: ((336)) 978--WISH Phone 336 978 WISH

W is h F u l fi ll me n t Ag r ee me n t
Wish Recipient:_____________________________________________________________________________

Primary Wish:______________________________________________________________________________

Secondary Wish:____________________________________________________________________________

1. Fulfillment of a Wish. In accordance with the terms and conditions of this agreement, The Sunset Wish Foundation agrees to pursue the fulfillment of the Wish of the person named above as the “Wish Recipient”. The Sunset Wish Foundation reserves the right and discretion to determine if a wish is to be fulfilled. Note: The Sunset Wish Foundation assists with wish requests for only the Wish Recipient and immediate family members (those persons living in the same household as the Recipient). 2. Permission to Disclose Medical Condition. The Wish Recipient grants the Sunset Wish Foundation the right to disclose the nature of his/her medical condition to the necessary to fulfill the Wish. In addition, the Wish Recipient grants the Sunset Wish Foundation permission to obtain personal medical information the Foundation deems necessary to fulfill the Wish. Further, the Wish Recipient authorizes his/her physicians and medical providers to release to the Sunset Wish Foundation all medical information necessary to consider fulfilling the Wish. 3. Relatives/Friends. No person may accompany the Wish Recipient during any portion of the Wish Fulfillment, unless there is prior specific written agreement between the parties. 4. Waiver. The Wish Recipient agrees to waive any and all rights he/she may have now or may have in the future against the Sunset Wish Foundation, including its officers, directors, volunteers, and employees, due to any injury, damages, or losses suffered by the Wish Recipient, or his/her family or friends, arising out of or in any way related to the Sunset Wish Foundation’s preparation, execution, or fulfillment of the Wish, whether any injury, damage, loss or harm is caused by any active, passive, or gross negligence of the Sunset Wish Foundation or any other person. 5. Release. The Wish Recipient and his/her relative and/or friends, together, and each of individually, agrees to forever release the Sunset Wish Foundation, its officers, directors, volunteers, and employees from any and all claims to and including, but not limited to, lawsuits, damages, or losses resulting out of or in any way related to the preparation, execution, or fulfillment of the wish by the Sunset Wish Foundation, including any damage or loss of whatever nature and extent suffered by the Wish Recipient and/or his/her relatives and/or friends, or anyone so related, whether such loss or damage is caused by the active, passive, or gross negligence of the Sunset Wish Foundation or any other person.

P..O.. Box 5703 P O Box 5703

Wiinstton--Sallem,, NC 27113 W ns on Sa em NC 27113

Phone:: ((336)) 978--WISH Phone 336 978 WISH

6. Our Protection. The Wish Recipient and/or his/her relatives and/or friends, together and each individually, agree to declare harmless and hold risk free and indemnify the Sunset Wish Foundation, including its officers, directors, volunteers, and employees, of and from any and all losses incurred by the Sunset Wish Foundation, including its officers, directors, volunteers, and employees, as the result of any claim against the Wish Recipient and/or his/her relatives and/or friends. This includes lawsuits, or any action arising out of or relating in any manner to the Sunset Wish Foundation’s preparation, execution, and fulfillment of the Wish. This also includes any breach by the Wish Recipient and/or his/her relatives and/or friends of the representations and warranties contained within the paragraphs of this agreement. This indemnification includes, but is not limited to, reasonable attorneys fees and costs incurred by the Sunset Wish Foundation, its officers, directors, volunteers, and employees, by retaining attorneys of the Foundation’s choice to defend any and all such claims, lawsuits, and actions. 7. Wish Expenses. The Sunset Wish Foundation agrees to pay for expenses that are expressly stated in writing and directly related to the fulfillment of the wish. The Wish Recipient and/or his/her relatives and/or friends, agree that they may be incur expenses outside the expressly stated written expenses as a result of unexpected events or circumstances outside the control of the Sunset Wish Foundation. The Wish Recipient and/or his/her relatives and/or friends, acknowledge that such unexpected expenses are more likely to occur if the Wish involves travel. The Sunset Wish Foundation assumes no responsibility or liability for expenses incurred by the Wish Recipient and/or his/her relatives and/or friends, that have not been expressly agreed to in writing prior to the start of the Wish fulfillment as agreed to in this agreement. Such expenses include, but are not limited to, those caused by unforeseen events or conditions beyond the control of the Sunset Wish Foundation, such as the need for extending a travel period away from the Wish Recipient’s home due to a deteriorating medical condition that results in necessary hospitalization beyond the period of time agreed to in writing prior to the start of the Wish Fulfillment. Other such expenses may include those which are medically-related, including hospitalization, for meals and lodgings, or for other goods, or services of any nature. Such expenses will remain the exclusive responsibility of the Wish Recipient and the Wish Recipient and/or his/her relatives and/or friends, agree to pay for all such additional expenses beyond those agreed to in writing prior to the start of the Wish Fulfillment. 8. Fundraising. The Wish Recipient and/or his/her relatives and/or friends, gives the Sunset Wish Foundation, in its sole discretions, permission to hold a Wish Fulfillment Campaign in your community, with your prior approval of any specific event or request, to assist in raising funds and/or Frequent Flyer Miles to help with the fulfillment of your Wish. The Sunset Wish Foundation agrees that any money or other benefits so raised by the Foundation will be used for your Wish. The Wish Recipient agrees that any money or miles raised above that necessary for your Wish will be used to help fulfill the wishes of other future wish applicants. 9. Representations and Warranties. The Wish Recipient and/or his/her relatives and/or friends, together and each of them individually, state truthfully the following:

P..O.. Box 5703 P O Box 5703

Wiinstton--Sallem,, NC 27113 W ns on Sa em NC 27113

Phone:: ((336)) 978--WISH Phone 336 978 WISH

a) This Wish Recipient’s medical condition as stated above is accurate and has been fully disclosed. b) The Sunset Wish Foundation will be notified as early as possible should the Wish Recipient’s medical condition deteriorate and make impossible or improbable the fulfillment of the Wish. c) The Wish Recipient is presently carrying, or will be carrying during the wish fulfillment period, full medical insurance, including any additional coverage made necessary to fulfill the Wish. If there are no provisions for this coverage, the Wish Recipient assumes the risk and personal responsibility of failing to carry adequate medical insurance. d) The Wish Recipient is able to personally pay for the monetary responsibility of possible extensive additional expenses which may arise as a result of unexpected circumstances or events outside the control of the Sunset Wish Foundation (as explained above), and the Wish Recipient assumes the risk of and personal responsibility to pay for such additional expenses. e) The Wish Recipient has not previously had a wish fulfilled by another charitable organization fulfilling wishes, not limited to and including the Sunset Wish Foundation. f) The Wish Recipient has not relied upon nor has the Wish Recipient been given guidance or advise from the Sunset Wish Foundation regarding the appropriateness of or the risks associated with the Wish. 10. Termination of the Wish. The Sunset Wish Foundation reserves the right, in its exclusive and sole discretion, to terminate the preparation and/or fulfillment of the Wish at any time after the execution of this Agreement, should the Sunset Wish Foundation determine any of the following: a) When the health and safety of the Wish Recipient or others will be at risk by the fulfillment of the Wish; b) When the Wish Recipient is presently, or will be, incapable of appreciating or utilizing the goods, services, or activities associated with the Wish; c) When current events or conditions render fulfillment of the Wish unrealistic, irresponsible, or unreasonable to fulfill or continue to fulfill the Wish; and d) When the Wish Recipient has broken this agreements or has made misrepresentations in the application of or fulfillment of the Wish or has made false and of the truths contained in this agreement. Should the Sunset Wish Foundation terminate preparation or fulfillment of the Wish for any reason, to and including those reasons stated above, the Wish Recipient and/or his/her relatives and/or friends, agree that the Sunset Wish Foundation shall not be held liable or responsible for any expenses which the Wish Recipient and/or his/her relatives and/or friends, may have accumulated in consideration of the Sunset Wish Foundation’s fulfilling the Wish. NOTE: The Sunset Wish Foundation, alone, is the sole and only person or entity permitted to make requests for resources in conjunction with fulfillment of the Wish. Unauthorized use of the name, images, resources and property of the Sunset Wish Foundation by the Wish Recipient and/or his/her relatives and/or friends, or those having knowledge of the Wish, to solicit support for the Wish or any other purpose may result in the immediate disqualification and termination of the Wish.

P..O.. Box 5703 P O Box 5703

Wiinstton--Sallem,, NC 27113 W ns on Sa em NC 27113

Phone:: ((336)) 978--WISH Phone 336 978 WISH

11. Further Assurances. In order for the Sunset Wish Foundation to plan, prepare to fulfill and carry out the Wish, the Wish Recipient and/or his/her relatives and/or friends, agree that they will, at the further request of the Sunset Wish Foundation, provide and deliver to the Sunset Wish Foundation all further documentation that the Sunset Wish Foundation deems necessary or appropriate. 12. Counterparts. This agreement may be executed in counterparts, any of which shall be deemed to be original. 13. Amendment. This agreement shall not be adapted or changed except in writing executed by the Wish Recipient and the Sunset Wish Foundation. 14. Governing Law. This agreement shall be governed by the laws of the state of North Carolina under whose laws the Sunset Wish Foundation is organized. 15. Binding Effect. This Agreement is binding on all heirs, successors, representatives, and assigns of all parties hereto. 16. Severability. If any portion of this Agreement shall be determined to be invalid or unenforceable, all other portions shall remain valid and enforceable. 17. Entire Agreement. This Agreement constitutes the entire Agreement and understanding of the parties with respect to the transaction contemplated hereby, and supersedes all prior agreements, arrangements, and understandings related to the subject matter. No representation, promise, inducement, or statement of intention has been made by any of the parties hereto not embodied in this Agreement, and no party shall be bound by or liable for any alleged representation, promise, inducement, or statements of intention not set forth or referred to herein. 18. Captions. The Captions appearing in this Agreement are for convenience and ease of reference only. They in no way describe, limit, or extend this Agreement or any of its provisions. 19. Proof of Financial Hardship. The Wish Recipient understands that the Sunset Wish Foundation reserves the right to request documentation of financial hardship. 20. Grant of Right of Publicity. PARTICIPANTS UNDERSTAND AND AGREE THAT FULFILLMENT OF THE WISH MAY RESULT IN PUBLICITY, WHETHER OR NOT THE SUNSET WISH FOUNDATION ACTIVELY TAKES STEPS TO PUBLICIZE THE WISH. Option 1: The Sunset Wish Foundation and participants hereby irrevocably authorize the Sunset Wish Foundation: (a) to publicize and use participants’ image, voices, and features, with or without their names, for any publication, promotion, trade, business use, or any other purpose whatsoever; (b) to photograph, videotape, film, and record each participant in any manner the Sunset Wish Foundation chooses; (c) to copyright, convey, or otherwise distribute, now or in the future, any such material involving the participants for any purpose to anyone, including the general public, magazines, newspapers, television, radio stations, or anyone else; (d) to publicize, now or in the future, the names of the participants including information regarding them, their physical, or emotional conditions and the details of any wish fulfilled.
P..O.. Box 5703 P O Box 5703 Wiinstton--Sallem,, NC 27113 W ns on Sa em NC 27113 Phone:: ((336)) 978--WISH Phone 336 978 WISH

The Sunset Wish Foundation and each of the participants agrees that it is not necessary for the Sunset Wish Foundation or anyone else to contact them prior to releasing any information authorized by this document. Each of the participants hereby releases the Sunset Wish Foundation from all liability, damages, or claims of any kind resulting in or from, or arising from the use, distribution or disclosure of any photographs, films, videotapes, electronic recording or other information regarding Participants and the wish. Initial here if Option 1 is selected __________________________ (must be initialed by all participants) Option 2: The Sunset Wish Foundation and participants request that the Wish not be actively publicized by the Sunset Wish Foundation to the news media and general public. However each of the participants understands that information regarding the Sunset Wish Foundation and the participants will necessarily be discussed with and disclosed to those involved in the Wish Fulfillment process. Each of the participants also understands that, even if the Sunset Wish Foundation does not actively publicize the wish, the general public and the news media may obtain information concerning the wish from other sources. Initial here if Option 2 is selected __________________________ (must be initialed by all participants) Each of the participants acknowledge reading and understanding this LIABILITY RELEASE AND PUBLICITY AUTHORIZATION prior to signing it. For any minor participants, the signature of their parent or guardian is both on behalf of the parent or guardian and on behalf of the minor. Each participant agrees that no oral or written modification of this Release has been made and this Release accurately and fully expresses the understanding of the Wish Recipient and each of the participants. IMPORTANT: By signing below, you affirm and acknowledge that you have read this Agreement, have received a copy thereof, and fully understand its provisions.

__________________________________
Sunset Wish Foundation Staff or Board Member

_____________
Date

Wish Fulfillment and Immediate Family Members Only (those who live in the same household):

__________________________________
Wish Recipient

_____________
Date

_______
Age

_________
DOB

__________________________________
Wish Participant

_____________
Date

_______
Age

_________
DOB

__________________________________
Wish Participant

_____________
Date

_______
Age

_________
DOB

P..O.. Box 5703 P O Box 5703

Wiinstton--Sallem,, NC 27113 W ns on Sa em NC 27113

Phone:: ((336)) 978--WISH Phone 336 978 WISH

HIPAA Release Authorization for Use/Disclosure of Protected Health Information
To:

______________________________________________________________
(Physician)

______________________________________________________________
(Physician’s Address)

______________________________________________________________
(Physician’s Telephone Number)

Re:

______________________________________________________________
(Patient – Print Name Legibly)

______________________________________________________________
(Patient’s Date of Birth) I authorize the use and disclosure of protected health information of the Patient to the Sunset Wish Foundation as follows: Information that can be used/disclosed: All protected health information relating to Physician’s assessments of: (a) whether Patient is medically eligible for the Sunset Wish Foundation’s services; and if so, (b) whether his/her desired wish is medically appropriate. In addition, Physician is authorized to complete, sign, and provide to the Sunset Wish Foundation forms that the Sunset Wish Foundation may require, including forms relating to Patient’s medical eligibility, the requested wish and medical considerations relating thereto. Persons authorized to use/disclose the information: The Physician identified above, as well as his/her authorized representatives. Persons authorized to receive the information: Employees or other authorized representatives of:

Sunset Wish Foundation * P.O. Box 5703 * Winston-Salem, NC 27113 Phone: 336-978-WISH * www.sunsetwishfoundation.com
Purpose for which information will be used/disclosed: To enable the Sunset Wish Foundation to obtain: (a) Physician’s assessments whether the Patient is medically eligible to have a wish fulfilled by the Sunset Wish Foundation and, if so, (b) whether the requested wish is medically appropriate; and (c) pertinent information relating thereto. Expiration date/event: This authorization expires at the earliest of the fulfillment of the Patient’s wish by the Sunset Wish Foundation, or a final determination that Patient is not eligible to receive a wish, or within one year of the date of execution. Statements required by HIPAA: In accordance with the Health Insurance Portability and Accountability Act, I acknowledge the following: a) I understand that I may revoke this authorization at any time by so notifying my Physician in writing, except to the extent that action has already been taken in reliance on the authorization; b) I understand that if the person/entity that receives the information described above is not a healthcare provider or health plan covered by federal privacy regulations, such information will no longer be protected by the HIPAA regulations and could potentially be re-disclosed by the recipient.

____________________________
Patient Name

______________________________
Patient Signature

_________________
Date

____________________________
Patient Representative

______________________________
Patient Representative Signature

_________________
Date

P..O.. Box 5703 P O Box 5703

Wiinstton--Sallem,, NC 27113 W ns on Sa em NC 27113

Phone:: ((336)) 978--WISH Phone 336 978 WISH

Mai li n g I n s tr uct io n s fo r Ap p l ica tio n
Your completed application package must include: 1 . Step I of the application completed with ALL required information. 2 . Step II of the application completed and signed by your doctor or hospice representative. 3 . Step III of the application completed and sent with your request letter of no more than one page, one sided, along with your photograph. 4 . Step IV of the application completed with the appropriate publicity items selected. 5 . Wish Fulfillment Agreement € Make sure to choose Option 1 or 2 on paragraph 20 and initial where indicated € Please make sure you sign you name and date the end of the agreement 6 . Medical Information Disclosure Form – Please read and sign. € Health Insurance Portability and Accountability Act (HIPAA) Release For help with completing this application, please call us at (336) 978-WISH and we will answer your questions. If we receive an incomplete application, it will not be processed. Please mail completed application to:

Sunset Wish Foundation P.O. Box 5703 Winston-Salem, NC 27113
Phone: (336) 978-WISH www.sunsetwishfoundation.com

P..O.. Box 5703 P O Box 5703

Wiinstton--Sallem,, NC 27113 W ns on Sa em NC 27113

Phone:: ((336)) 978--WISH Phone 336 978 WISH