• Magical Memories for Special Kids

Montreal
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Agency or Organization Application

Name of Agency or Organization: *
Name of Agency or Organization Rep
Name:
*
Rep Cell Number: *
-
Agency or Organization Number: *
Rep Home Number: *
-
Email: *

Note:You must provide contact information that is valid between now and the flight date. If your agency closes for the summer - our DTF Directors still need to contact you! Do NOT provide contact information that may not be valid during certain times of the year - specifically for school applications.

Address of Agency or Organization:
Agency or Oganization Mission Statment: *

Additional Information:

Is there any reason that a nominated child or children from you agency or organization CANNOT be mixed with all the other children - by age & gender? *
If "YES" please explain:
Is an agency or organization rep required to accompany any of your nominated children for the flight?
If "YES" please explain :
Additional Comments:

Agency / Organization Acknowledgements:

1. As the Agency or Organization rep, I have read and fully understand the requirements as noted in the "Child Selection" Tab on the DTF Website: *
2. As the Agency or Organization Rep, we will be fully responsible for compliance of DTF Child nominations and the agency may be responsible for FULL expenses of the trip, reimburesed to DTF, if found in non-compliance. Non-compliance could also result in denial of future applications: *
3. As the Agency or Organization Rep, I fully understand all nominated children for the 2014 flight, will require a valid Canadian Passport, at the agencies expense. Some governmental aid may be available: *
4. As the Agency or Organization Rep, We fully understand the children we select for the 2014 DTF Program are often segregated, usually by age & gender: *
5. The Agency or Organization acknowledges that this a 100% non-smoking and NO cell phone day: *
Date Application Submitted (DD/MM/YR): *
Enter the Code Shown: *

Dreams Take Flight Montreal - By submitting this form, your Agency or Organization has agreed to all the terms of the Child Selection tab on our DTF Montreal Website. Also all the information submitted in this form can be used by the Directors of DTF Montreal. As always, privacy is very important to us, no information is ever shared or given to any outside agencies.

Once Complete and Ready to Submit - Please Hit SUBMIT

(*) Fields are Mandatory