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Due to a website error, Wishes submitted between 2/8/12 and 2/16/12 were not received in our database. If you submitted a Wish during that time, please resubmit the Wish below or contact Nick Eaton at nick@seniorwish.org or 303-954-9144 ext. 15 Please Note: If you are filling this application out on behalf of someone other than yourself, please fill out each section in accordance to the nominee's information.
Section A: Contact Information
Senior
*Senior Name:**

*Senior Phone Number:**

*Address:**

*City:**

*State:**

*Zip:**

*Birthday:**		//

Email:
Nominator		(If applicable)
Nominator Name:

Nominator Phone Number:

Address:

City:

State:

Zip:

Email:

Relationship to Wish Nominee:
Section B: Wish Detail
Please be specific in your answers, and include as much detail as possible.

Describe your Wish of a Lifetime*

Explain the history behind this wish?* For example: What prompted this wish? Do you know how long have you wished for this? What is the story behind this wish? When did you know or first realize you wanted this wish?

What makes this wish meaningful to you?* For example: Describe your mental, emotional, physical, or spiritual connection with this wish.

How would fulfilling this wish positively impact your life?*

What has prevented you from fulfilling this wish on your own?*
Section C: Personal History
Before we move forward with a wish, we would like to try and get to know you. Please take the time to tell us a little about yourself.
Please Note: If you are filling this application out on behalf of someone other than yourself, please fill out each section in accordance to the nominee's information.

What were your past occupations, if any?*

What are some of your interests, hobbies, and passions? What have you done to give back to others?* For example: Tell us about your friends or family, any volunteer work or military service. If you are a veteran, please list the branch you served in and the details of your service.

Have you ever been convicted of a crime?*		Yes No
If yes, please provide details:

Are you a legal resident or citizen of the U.S.?*		Yes No

Do you have any physical or cognitive impairments that may influence your ability to participate in the wish?*		Yes No
If yes, please provide details:

Section D: Medical Verification and Liability Release
Medical Verification Form - If your wish involves any extreme physical activity or travel of any kind, please have your doctor sign and submit the Medical Verification Form. Medical Verification Form can be downloaded here. Photo and Liability Release - Please sign and submit the Photo and Liability Release Form along with your application. Receipt of the signed liability section is required for wish fulfillment. Photo release section is optional, but encouraged. Photo and Liability Release Forms can be downloaded here.

Certification:
Please click to certify By checking this box, I acknowledge that acceptance of this application by Jeremy Bloom's Wish of a Lifetime (JBWOL) does not constitute a commitment by JBWOL to fulfill my wish request. If JBWOL determines that this wish should enter the next stage of the wish process, a JBWOL representative will contact me for more information. I understand that this contact also does not constitute a commitment to grant my wish. Furthermore, I certify that I meet all qualifications for eligibility, and declare that all of the information given by me in this application is true to the best of my knowledge, and I agree to inform JBWOL in a timely manner should any information provided in this application change. I would like to receive your monthly newsletter!

Disclaimer:
Unfortunately, Jeremy Bloom's Wish of a Lifetime is unable to grant every qualified wish we receive. The decision to grant a wish is at the sole discretion of Jeremy Bloom's Wish of a Lifetime, and a wish may be denied for any reason.

If you prefer you can download the Wish Slip and send it to:

Wish Committee
Jeremy Bloom's Wish of a Lifetime
1821 Blake Street
Ste 200
Denver CO 80202

Sample of Wishes Granted

Nancy
We traveled with Nancy to visit her daughter in Arizona who is battling cancer. While the circumstances are unfortunate, we are incredibly excited to have provided an opportunity Nancy otherwise would not have to spend a few precious days with her daughter.

Aleks and Tamila
We recently granted the wish of Aleks and Tamila - Russian immigrants who lost everything they had in the collapse of the Soviet Union in 1991. When asked, they told us they have always dreamed of fishing together. Our foundation recently granted their wish and took them to Keystone to spend the day fishing on a private lake high in the Rocky Mountains.

View more sample wishes granted

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Sample of Wishes Granted