Make a Kid’s Dream Come True!

Know a child getting treatment for a life-threatening or debilitating condition in the East Tennessee region? Let us know – and we’ll do our best to connect them to a once-in-a-lifetime experience!

Dream Connection Nomination Form

First, tell us about YOU:

Your Name(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Your Email Address(Required)

Your Phone Number

Next, tell us about this special child:

Child's Name(Required)

First Last

Child's Birthdate(Required)

Must be 3 to 18 years old to qualify

Has this child received a dream from another agency?(Required)

Yes

Are You the Parent/Guardian of This Child?

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Parent 1 Name(Required)

Parent 2 Name

Family's Address(Required)

Street Address Address Line 2 City State ZIP Code

Email Address(Required)

Phone Number

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Name of Facility Where Child Receives Treatment(Required)

Treating Physician's Name (optional)

Facility's Phone Number(Required)

Finally, tell us how you know this child and what makes them dream-worthy:

Tell us about the Child's Medical Condition:(Required)

Finally, Tell Us How You Know This Child and Why You're Nominating Them:(Required)