Jorge Nation Foundation, Inc. Dream Trip Application

(Please follow all directions and answer all fields to the best of your ability)

All medical and private information obtained is considered confidential and is not discussed with any third parties unless it is necessary for the Dream Trip and the applicant’s parent(s) or legal guardian(s) has/have given JNF consent.

Click here to read the requirements for a Dream Trip.

Name of Dream Trip Applicant:*
Age:*
Applicant’s DOB:*
MM slash DD slash YYYY
SSN:*
Birth Place:*
Address:*
(city, state)*
(zip)*
Email of person submitting this application*

Important: You will receive email confirmation with additional request for information.
Tel:*
School (if applicable):*
GPA (if applicable):
Names of Parents/Guardians of Dream Trip Applicant:*
Relationship(s) to Applicant:*
Address:*
(city, state)*
(zip)*
Tel:*
Occupation(s):*
Employer(s) Name and Address:
Employer Tel:
Employer(s) Email(s):
Requester’s Name (if different):
Relationship to Dream Trip Candidate:
Date
MM slash DD slash YYYY
SSN:
Address (if different than applicant’s):
(city, state)
(zip)
Home Tel:
Work Tel:
Cell Tel:
Email:
Hidden
Twitter, LinkedIn, or Facebook: (Circle if Yes)
- Twitter
- LinkedIn
- Facebook
EMERGENCY CONTACT:
Relationship to Applicant:
Address (if different than applicant’s):
(city, state)
(zip)
Tel:
Applicant Email:
List all scholastic achievements and awards of the Dream Trip candidate, if any:
List all extracurricular activities of the Dream Trip candidate, if any. Please indicate whether they are school or non-school related; include honors, awards or special recognition:*
List favorite activities and special interests, hobbies and sports, of the Dream Trip candidate:*
Brief description of Dream Trip candidate’s medical condition, illness, disability, or hardship:*
Description of all medical providers of Dream Trip candidate with knowledge of above:*
Description of the candidate’s ideal Dream Trip (see requirements below), please provide detailed information about the request including dates requested, and members of the family, their relationship to the candidate, and their ages, which would attend with Dream Trip candidate:*
If there are any circumstances that you feel have created a need for financial assistance in order for the Dream Trip candidate to be awarded a Dream Trip, please explain:*
Please identify any members of your family (include their relationship to you or the applicant) who have been awarded any similar dream trip, wish, or charitable contribution from JNF or any other organization:*
Additional comments that JNF should consider in considering candidate’s Dream Trip application:
I hereby certify all information submitted above to the Jorge Nation Foundation, Inc. is true and accurate.*
- I hereby certify all information submitted above to the Jorge Nation Foundation, Inc. is true and accurate.

SPECIAL INSTRUCTIONS:

Upon submitting your application by clicking the SUBMIT button above, you will receive a confirmation email with a request for the documents below. Your application will not be complete unless you submit the following:

Medical statements from the Dream Trip candidate’s medical providers confirming the applicant’s condition or illness, if applicable; and
Medical clearance from the Dream Trip candidate’s physician(s) for the desired Dream Trip destination and dates ; and
Proof of Identification for the applicant, if any, and parent(s)/legal guardian(s); and
A brief written statement discussing why the applicant should be considered for the Jorge Nation Foundation’s Dream Trip, including a description of the applicant’s illness or medical condition and a description of the applicant’s desired Dream Trip. Add anything you think will be helpful to the Dream Trip Committee in its confidential consideration of your application. Please limit the written statement to two (2) pages total, double-spaced, and twelve (12) font.

PLEASE NOTE: We may require additional information from you and/or the Dream Trip candidate, including documentation from his/her medical providers or the family, in connection with the Dream Trip Application before we grant a Dream Trip to a candidate.

Jorge Nation Foundation, Inc. Dream Trip Application

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