NOMINATION REQUEST - FORM A

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To nominate a child or a teenager with a serious illness please complete this form:

 


 

 

 

 

 
Nature of Illness *
Date Diagnosed *
Details of Current Medical Treatment *
Name of Hospital Where Child/Teenager is Treated *
What Equipment will you bring with you *
(ie, Wheelchair/Oxgen etc..)
Has this child/teenager ever had a holiday in Disneyland Florida or Paris? *
If you answered YES above, please give the approximate date
Has this child/teenager ever had a holiday in Blackpool? *
If you answered YES above, please give the approximate date
Please list other people who will stay with the child/teenager *
Name:
Age:
Relationship to Child:
Name:
Age:
Relationship to Child:
Name:
Age:
Relationship to Child:
Name:
Age:
Relationship to Child:
Name:
Age:
Relationship to Child:
Please specify your preferred holiday dates * (we are unable to guarantee availability) Choice 1:

Choice 2:

Choice 3:

Email Address *
Today's Date *
Electronic Signature *
Please put your initials in the box provided
   
We would like to keep your details on file, please un-tick the box if you do not want us to keep your details on file.

We will NOT share your personal information with any 3rd parties.












 


 


If you would like to donate via PayPal you can do by selecting one of the buttons below. PayPal is a totally secure method of making a donation.
Donate any amount Donate £1 Donate £5 Donate £10 Donate £25 Donate £50 Donate £100 Donate £250 Donate £500 Donate £1000

(These costs are approximate, but it gives you an idea of the pressure placed upon Donna's Dream House to keep going).

GIFT AID

Under the Gift Aid scheme, we are able to claim an extra 25% from the Government on every eligible donation made by a UK taxpayer. For example, on a £100 donation we can reclaim £25, making your donation worth £125 – at no cost to you or our charity.

How it works
When you donate to Donna’s Dream House, you will be asked to confirm whether or not you are a UK taxpayer. Gift Aid can only be reclaimed on donations made by individuals who pay UK income or capital gains tax at least equal to the amount reclaimed on their donations in the current tax year.


Download a Gidt Aid Form

Simply click the button above to download a Gift Aid Declaration Form. Then print it out, fill it in and post it to us. We'll do the rest.

Thank you!