Application for A Heart’s Desires Foundation Services

Eligibility.

Individuals must meet the following criteria at the time of application:

Diagnosed with a terminal illness, such as a progressive, degenerative, or malignant
condition in which the individual has a life expectancy of twelve months or less.

Application Source.

Applications must be submitted by an approved application source (see
below) to be considered by A Heart’s Desires Foundation. A Heart’s Desires Foundation will
only contact individuals or their families if referred by an approved application source.

To respect the privacy of those we serve, eligible individuals can be referred by:

● Individuals being treated for terminal illness.
● Medical professionals, hospice care providers, and social workers.
● Family members with detailed knowledge of the individual’s medical condition.

Application Process.
If you are an approved application source of an eligible individual, please submit this application to A Heart’s Desires Foundation, P.O. Box 4613, Sevierville TN 37864. If you are not an approved application source, please share this form with the individual or their family. The individual’s healthcare provider must submit in writing whether the individual is medically eligible to receive, and is appropriately able to participate in, their requested desire.

The individual, or their legal guardian, and any other person participating in the requested desire must submit in writing the “Liability Release and Authorization Regarding Medical Information and Publicity” attached at the end of this application form before the requested desire can be granted. Please note that A Heart’s Desires Foundation does not fulfill desires relating to travel outside of the United States.

Nondiscrimination Statement.

A Heart’s Desires Foundation believes that all people facing a terminal diagnosis deserve to have a desire fulfilled regardless of race, color, religion, creed, gender, gender expression, age, national origin, disability, marital status, or sexual orientation.

No Guarantee.

A Heart’s Desires Foundation takes every desire seriously and promises to
provide ample consideration of each desire. However, nothing in this application shall be
construed as a promise by A Heart’s Desires Foundation to fulfill any specific desire or to take any action. A Heart’s Desires Foundation reserves the right to grant or deny desires for any reason, including feasibility and the availability of funds. If A Heart’s Desires Foundation decides to move forward with desire fulfillment, A Heart’s Desires Foundation may, in its sole discretion, impose specific terms and conditions upon the fulfillment of the desire.