Golden Wishes. For more information contact Jessica Armstrong: or

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1 Golden Wishes ABOUT Golden Wishes grants special wishes for deserving seniors in Miami-Dade County. The goal is to celebrate, honor and value those age 70 and older by engaging volunteers, companies and sponsors to make long-held dreams a reality. ELIGIBILITY Nominees must be 70 and older, and live in Miami-Dade County. The committee is seeking truly meaningful and compelling wishes for deserving seniors who are without the means to fulfill their wish on their own. Nominations are welcome from friends, co-workers, relatives and service providers. Individuals can also nominate themselves. TYPES OF WISHES GRANTED Learning and/or new experiences (e.g., first-time tickets to the Adrienne Arsht Center for the Performing Arts, tuition for a class, swimming with dolphins, etc.) Connecting with friends and/or family (e.g., traveling to a family reunion, meeting a grandchild for the first time, reconnecting with a long-lost friend, a special girls or guys night out, etc.) Solutions (e.g., overcoming a barrier, replacing a broken appliance, help carrying bags after a planned purchase, etc.) Other wishes with significant meaning to the recipient Wishes will not be granted for cash, automobiles, real estate, major home renovations, legal services, medical treatments or other wishes (at the discretion of the volunteer selection committee). NOMINATION FORM INSTRUCTIONS {EXTENDED} DEADLINE: Friday, January 19, 2018 by 5:00pm To nominate yourself or someone else, simply fill out the nomination form on the following pages and it to goldenwishes@unitedwaymiami.org. Alternatively, you may drop the nomination form off in-person or mail it to: United Way of Miami-Dade Re: Golden Wishes 3250 SW 3 Avenue, Miami, FL Mailed applications must be postmarked by the due date and time in order to be considered. For more information contact Jessica Armstrong: goldenwishes@unitedwaymiami.org or

2 Golden Wishes NOMINATION FORM Today s Date: / / (MM/DD/YYYY) A. NOMINEE PROFILE (i.e., the person you d like to receive the wish) Nominee s Contact Information: First Name: Last Name: Address: Senior Living Facility Name (if applicable): Cell Phone #: - - Nominee s Demographics & Language: Home Phone #: - - Year of Birth: Gender: Female Male Other Language: About the Nominee: English (receiving all communications in English is OK) Spanish only Haitian Creole only Spanish preferred, but some English is OK Haitian Creole preferred, but some English is OK Other / Additional comments: 1. Past occupations/careers: 2. Interests, hobbies or other passions: 3. Are there any physical or cognitive impairments (or other) that may influence the nominee s ability to participate in the wish? (Golden Wishes will make every effort to accommodate impairments when planning Wishes.) Yes (please describe: ) 4. To the best of your knowledge, if the nominee s wish is selected to be granted, is it likely the nominee will be able to attend a wish granting ceremony in Miami in February/March 2018? Yes the nominee is likely to attend No No the nominee is not likely to attend 5. To the best of your knowledge, what best describes the nominee s transportation situation: Has a car and drives self Often takes public transportation Has reliable family, friends or service to provide transportation Requires other transportation solution be provided

3 B. NOMINATOR INFORMATION I am filling out this form to: Nominate myself for a wish Nominate someone else for a wish If you are nominating yourself, do not fill out section B (below). Go directly to section C. WISHES. Please fill out this section only if you are nominating SOMEONE ELSE. Nominator s Contact Information: First Name: Last Name: Cell Phone #: - - Additional Nominator Information: Home Phone #: What is your relationship to the nominee? (e.g., family, friend, service provider, doctor, etc.): 2. If your nominee s wish is selected, please check all the ways you may be able to participate with Golden Wishes: Liaison: I can link the wish fulfillment team to the nominee at key points during the process. Attendee: I m interested in attending the wish granting ceremony at United Way in February/March 2018 to celebrate alongside my nominee. Transportation: I may be able to give my nominee a ride to the wish granting ceremony, if needed. Wish Fulfillment Team: I can be part of the hands-on wish fulfillment team responsible for planning and executing the overall wish of my nominee. Sponsor: I can sponsor (financially or in-kind) and/or coordinate sponsorships through my company, place of worship, club(s), organization(s), etc. to fulfill some or all parts of the wish. Other: There are other ways I would like to participate or contribute to the success of this wish (please describe):

4 C. WISHES As part of your nomination, you may submit up to three wishes (a first-choice wish, and alternate second- and third-choice wishes). If your first wish is particularly costly, providing less-costly options as second and/or third wishes is recommended. 1 First Choice Wish Description: What is the wish you envision? Please provide as detailed a description as you can. (100 character minimum) Value: What will make this wish so special, meaningful and impactful for the recipient? 2 Alternate: Second Choice Wish Description/Value: 3 Alternate: Third Choice Wish Description/Value:

5 D. SPECIAL CONSIDERATIONS 1. What else can you share about the nominee relevant to the goal of granting wishes to a truly deserving senior? Here are some questions to help you think (these are not required questions): What is your motivation for wanting to honor, value and celebrate the nominee? What special contributions has/is the nominee making to their family, friends, neighbors and/or community? How long has the nominee been interested in this wish? Is the wish something the nominee has ever done before? Is it beyond the means of the nominee to achieve this wish on their own? E. SIGNATURE (Nominee if self-nominating or nominator if nominating someone else) By submitting this wish, I acknowledge that acceptance of this application by Golden Wishes (GW) does not constitute commitment by GW to fulfill my wish request. If GW determines that this wish should enter the next stage of the wish process, a GW representative will contact me for more information. I understand that this contact also does not constitute a commitment to grant my wish. Furthermore, I release GW from all liability relating to injuries that may occur in the process of granting the wish. By signing the application form, I agree to hold GW entirely free from any liability, including financial responsibility for injuries incurred, regardless of whether injuries are caused by any circumstances. Print Name: Signature: Did any service provider assist you in completing a self-nomination? If so, provide: Staff name: Organization: Phone #: - -