Nomination Form

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Please note the child should NOT be told of the nomination to avoid disappointment if not selected

Any nominations received after the cut off dates will be considered for the next year’s trip.
CHILD'S DETAILS


The age limit for our Orlando trip is 8-14 years and the UK Activity Trip 8-16.
We are currently accepting nominations for children with a birthdate between 01/03/2011 and 24/10/2018

enter format as dd/mm/yyyy. 


May be able to do standing transfer, but would need to be lifted for any distance and/or up any steps
The max weight criteria for the Orlando trip if fully wheelchair dependent is 50kg. The max weight criteria for the UK Activity trip if fully wheelchair dependent is 70kg.

Enter a number only.

Enter a number only
The max weight criteria for the Orlando trip if fully wheelchair dependent is 50kg

Enter a number only.
The max weight criteria for the UK Activity trip if fully wheelchair dependent is 70kg

Enter a number only.
If the child is between 50-70kg you can nominate them for just the UK Activity Trip, change your selection from both trips to just UK Activity trip above


enter a number only
CHILD'S ADDRESS




School attended






Parent/carer 1 details





Parent/carer 2 details





NOMINATED BY











DIAGNOSIS

include GMFCS score if known

MOBILITY





PERSONAL INFORMATION

Please tell us why you have nominated this child. Any relevant information e.g. onset of illness, impact on child and family, prognosis, siblings, who cares for them. This background information is essential for the selection process.








Note: Dreamflight is unlikely to be an appropriate experience for children with significant global developmental impairment (as a guide, a functional age of <7 years}.


Please describe and give details of any behaviour plan that is in place if known


Please give further information including support in place and any CAMHS involvement


Please confirm that you have read the neurodivergence guidance and discussed with parents/carers. Please give further details
TREATMENT THAT MAY BE REQUIRED ON THE TRIP


Please include medication information including names of current medication if known










Eg. does the child use a sleep system, have sleep difficulties or other needs




Please give further details and specify if the child needs invasive or non invasive ventilation and if ventilation is overnight or 24 hours. If 24 hours, can the child tolerate any time off ventilation?



Please give further details about monitoring requirements. Please note that we are unable to provide continuous 1:1 care. Overnight monitoring is remote with a night nurse team making regular rounds and responding to monitor concerns.

A further printed swab result will be required, dated not before 01/10/2021
DISNEY EXPERIENCE

This will not necessarily preclude the child from being selected for Dreamflight
Nominated for Dreamflight before


MOVING AND HANDLING


If requires assistance to transfer then please give details.




Name, position and phone number
OTHER HEALTH PROFESSIONALS

If the child’s care is shared with another medical team, please ensure they are aware of this nomination.

SOCIAL SERVICES


CONSULTANT/ASSOCIATE SPECIALIST AND HOSPITAL






MEDICAL AUTHORISATION

GP DETAILS







We'd like to stay in touch with our nominators!

If at any time you would like to change your preferences, please contact us by email to office@Dreamflight.org or by telephone on 01494 722733.  Thank you.
All personal data provided on this form will be stored in a secure manner in compliance  with the recommendations of the Data Protection Act and will be used only for Dreamflight purposes.
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