Wish Holiday Application Form - The Pied Piper Appeal | makes a difference to sick and disabled children in Gloucestershire.

Have you read our Guidelines for Parents and Health/Social Care Professional" document?

Yes

All holidays offered in the "WISH HOLIDAY" PROGRAM are taken within Europe - We do not provide funding for Holidays outside of Europe. Please tick this box to show you understand

Yes

Name of Child

Date Of Birth

Medicatial Condtition(s)

Address

Postcode

School Attended

Home Telephone

Moblie Telephone

Email

Are You A Single Parent

Name Of Parent

Parent (1) DOB

Name Of Parent

Parent (2) DOB

Names and D.O.B of all SIBLINGS/immediate family living at the same address. (Please note Pied Piper is only able to fund siblings 18yrs or younger and still in education.)

*where a carer is required, Pied Piper will assess the application on a case by case basis, please email to let this known at time of application. PLEASE ENCLOSE a small PHOTOGRAPH OF YOUR CHILD. Photo has/ not been sent No file chosen

A MEDICAL SUPPORT LETTER from a medical professional involved in your child’s care will be needed as an IMPORTANT part of the application process. No file chosen

Would you like to attach a letter from parents

No file chosen

*Pied Piper covers the travel and accommodation package at time of booking. *Would you require an accessible room? Yes/No

*Sharing stories of the positive impact that Wish Holidays make to sick and disabled children and their families helps us raise awareness of the work we do, encouraging more people to donate to our fundraising efforts and enabling more children and their families to benefit. We share stories internally to motivate our staff and volunteers, externally in newsletters and other promotional materials published on our social media channels, our website, and in wider media, and also during talks and presentations about the work of the charity. The information included is limited to first names, very brief details of the illness or disease, the region of the UK where you are based, photographs and video of a thank you message and/or of the Wish Holiday being enjoyed, and the impact it had. If you do not give permission for Pied Piper to share your story this will not have any detrimental effect on your application. You may ask us to stop using your story, and your likenesses, at any time. I give my permission for my child’s/family’s story, plus our likenesses including in photographs and videos provided by us, to be used by Pied Piper for the purpose of promoting the charity and Wish Holidays as described above Yes/No

Wish Holidays Application Form

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