Form for Translation Nominating Agency*Please choose oneVancouverEdmontonCalgaryWinnipegTorontoOttawaMontrealHalifaxBase InfoName of Nominated Child* First Last Is this child an ALTERNATE?* Yes No Agency Contact InformationName of Agency Contact* First Last Agency Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Office Phone*Emergency Cell*Agency Email* Enter Email Confirm Email Child Selection CriteriaThe child is a Canadian citizen:* Yes No The child has a Canadian Birth Certificate or Canadian Passport:* Yes No The child experiences physical, mental or social issues:* Yes No It is understood the child MUST be cleared as per the medical criteria of the DTF medical team:* Yes No The child's family is in a financial situation that would not allow for a trip of this nature on their own:* Yes No IF YOU HAVE ANSWERED "NO" TO ANY OF THESE QUESTION - STOP! You need to contact the Dreams Take Flight Agency Director - ASAP.An answer of NO - May not qualify the child to be apart of this program. If the child meets the above basic criteria, please proceed to the next set of questions.Are the parents of the child an Air Canada employee?* Yes No Has the child been to a Disney or Universal type theme park:* Yes No Have the parents of the child, travelled outside of the Province in the past 12 Months?* Yes No Has this child ever been on an airplane:* Yes No The Dreams Take Flight program is NOT to be used as a reward program for schools or agencies. Has the child selected because of a school or agency reward?* Yes No IF YOU HAVE ANSWERED "YES" TO ANY OF THESE QUESTION - STOP! You need to contact the Dreams Take Flight Agency Director - ASAP.An answer of YES - May not qualify the child to be apart of this program. If the child meets the above basic criteria, please proceed to the nomination documents that follow.Legal FIRST Name (as it appears on the Birth Certificate)* Legal LAST Name (as it appears on the Birth Certificate)* Preferred FIRST Name* Date of Birth* DD slash MM slash YYYY Age (On day of flight)*Please enter a number from 1 to 14.Gender* Male Female Birth CertificateBirth Certificate Registration Number* Issuing Province / Territory*Please choose oneAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonUpload scanned copy of Birth Certificate Drop files here or Select files Max. file size: 50 MB. Passport InformationOnly to be filled out if the child does in fact have a Passport. Passport Number Date of Expiry DD slash MM slash YYYY Country of IssuePlease choose oneAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwePlace of Issue Provincial Medical CardHealth Card Number* Issuing Province / Territory*Please choose oneAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonChild ParticularsEye Colour* Hair Colour* Height (in centimeters)* Weight (in kilograms)* Birth marks, scars, etc* Wears Glasses* Yes No Child ClothingT-shirt Size*Please choose oneChild - 8Child - 10Child - 12Child - 14Child - 16Adult - SmallAdult - MediumAdult - LargeAdult - X LargeAdult - 2X LargePants Size*Please choose oneChild - 8Child - 10Child - 12Child - 14Child - 16Adult - SmallAdult - MediumAdult - LargeAdult - X LargeAdult - 2X LargeShorts Size*Please choose oneChild - 8Child - 10Child - 12Child - 14Child - 16Adult - SmallAdult - MediumAdult - LargeAdult - X LargeAdult - 2X LargeJacket Size*Please choose oneChild - 8Child - 10Child - 12Child - 14Child - 16Adult - SmallAdult - MediumAdult - LargeAdult - X LargeAdult - 2X LargeHoodie Size*Please choose oneYouth - SmallYouth - MediumYouth - LargeYouth - X LargeAdult - SmallAdult - MediumAdult - LargeAdult - X LargeAdult - 2X LargeShoe Size*Please choose oneChild 10Child 11Child 12 (182mm)Child 13 (190mm)Junior 1 (198mm)Junior 2 (206mm)Junior 3 (214mm)Ladies 5 (221mm)Ladies 6Ladies 7Ladies 8Ladies 9Ladies 10Ladies 11Ladies 12Men 4 (221mm)Men 5Men 6Men 7Men 8Men 9Men 10Men 11Men 12Men 13Men 14Parent or Legal Guardian InformationStatus of Child*Please choose oneLives with both parentsMother with sole custodyFather with sole custodyParents with joint custodyOther family member with custodyFoster ParentWard of the StateOtherDefine 'Other'* Is there a custodial agreement between the parents that require both parents approval for travel* Yes No If YES, Please Stipulate*Parent / Guardian Name* First Last Home Phone*Cell Phone*Work PhoneEmail Address* Address of Parent / Guardian* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Does the child live at the above address also?* Yes No Please provide actual legal address*If NO, Please Provide the Childs Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Emergency/Alternate Contact InformationThis information must be valid and available from the time when children are dropped off at the airport in the morning and until the children are picked up in the evening.Name of Emergency Contact* First Last Relationship to Child* Emergency Contact Home Phone*Emergency Contact Cell Phone*Emergency Contact Work Phone *Very Important: if any of the above contact information changes from now until the day of flight, it is the parent or guardian's responsibility to keep the agency updated. Failure to do so could result in the removal of the child from the flight!Child Medical DeclarationDoes the Child have a pre-existing medical condition?* Yes No If YES, does the child have medical coverage which covers travel to the USA?* Yes No If YES to either of the above please provide details*Does the Child have any allergies?* Yes No If YES, please explain*Does the Child have any special dietary requirements?* Yes No If YES, please explain*Does the Child have any special needs (include behavioral or phobias)?* Yes No If YES, please explain*Is the Child taking any medication?* Yes No If YES, please provide name, dose, frequency & time*Does the Child require a wheelchair?* Yes No Child Insurance DeclarationIf YES is the answer to any question below, please ensure to provide more information in the text box provided right after the question.Has your child ever required or received medical treatment or prescription medications for heart / cardiovascular condition or a stroke / cerebral vascular condition or an aneurysm?* Yes No Please provide more details*In the past 12 months (6 months for high blood pressure) has your child received any new prescription medication or new medical treatment for any medical condition?* Yes No Please provide more details*In the past 12 months (6 months for high blood pressure) has your child had any prescription medication changed, reduced, stopped or increased for any medical condition? (not including a change between brand name & generic brand)* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had lung/respiratory condition?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had diabetes which is controlled by diet, medication, or with insulin?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had any test, investigation, or surgery recommended but not yet completed?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Cancer or Leukemia?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had blood disorder?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Kidney disorder requiring dialysis or Liver disorder?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Circulatory disorder of the arteries or veins?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Pancreatic disorder?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Muscle, Bone, Joint disorder (not arthritis)?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Stomach or Bowel disorder?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Urinary disorder?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Parkinson's disease or Seizures?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had High Blood Pressure (Hypertension)?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Prostate disorder?* Yes No Please provide more details*In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had any other pre-existing condition currently requiring medication?* Yes No Please provide more details*Anything else we should know?Additional Child InformationDoes your child require assistance to sit upright and walk?* Yes No Please provide more details*Does your child have problems with bowel or urinary functions?* Yes No Please provide more details*Does your child require supplemental oxygen?* Yes No Please provide more details*Does your child require a feeding tube?* Yes No Please provide more details*Does your child use any special devices which are required at all times?* Yes No Please provide more details*If you have answered YES to any of the above, is there anything else we should know?Anything else?Extra child information:If there is anything else Dreams should know about the child to ensure a fun and safe day that has not already been covered or if you would just like to provide additional detail towards anything that has already been covered, please enter it here.Agencies NoticeIt looks like you're located at a chapter that has it's own site. Please click your location below: Edmonton Calgary Ottawa Vancouver Toronto Montreal Winnipeg Halifax
