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Senior Name:

Senior Phone Number:

Address:

Cit :

State: Zip:

Birthdate: Email:

N ( )

Nominator Name:

Nominator Phone:

Address:
Cit :
State: Zip:

Email:

Relationship to Wish Nominee:

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S B: D

P .

1. What is our Wish of a Lifetime?

2. E plain the histor behind this ish:

2a) ? (300 )

2b) ? (100 )

2c) ? (100 )

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3. Describe an benefits (emotional, ph sical, spiritual, social or intellectual) ou think ou ill
e perience as a result of having this ish granted: (100 )

4. Ho ould granting this ish inspire others and help WOL in their goal to change the a
people vie aging?

This ish and/or m stor ill inspire others because (100 )

5. Wh are ou unable to fulfill this ish on our o n? (100 )

5a) Have ou done this before? If so, ho long has it been?

5b) If ou are looking to reconnect ith someone, hen as the last time ou sa them?

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S C: P H

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.N a : P ea e e e be a a e
efe e d d a be a ed f a .

1. What ere our past occupations, if an ?

2. What are some of our interests, hobbies, and passions? Do ou still participate in an of
these toda ? (100 )

3. What have ou done to give back to others? (100 )

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3. Have ou ever been convicted of a crime? Yes No

If es, please provide details:

4. Are ou a legal resident or citi en of the U.S.? Yes No

5. Are there an ph sical or cognitive impairments that ma influence our abilit to participate
in the ish? (Please consider accommodating for heelchairs, o gen, dementia care, etc.)
Please note: WOL tries to make ever effort to accompan for cognitive and ph sical
impairments hen planning Wishes.

Yes No

If es, please describe, and let us kno hat accommodations ill need to be made to enable the
Senior to fulfill his/her ish:

+RZGLG\RXKHDUDERXW:LVKRID/LIHWLPH" (Please be specific)

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S D: M V L R

Medical Verification Form I

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Liabilit Release and Medical Information Authori ation P

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Publicit Waiver and Release P ,

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Wish of a Lifetime
303 E 17th Ave Suite 850
Denver, CO 80203
O 303-648-5626

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Signed Name:

Printed Name: Date:

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 W A ca Med ca Ve f ca F

I certif that I am the primar care ph sician for . I am aware

(Name of individual

of the wish that the individual has submitted to Wish of a Lifetime, and I hereb verif that the individual is ph sicall

and ps chologicall capable of participating in all activities pertaining to their wish.

Signature: Date:

If A cab e: I give m permission for the individual to travel via plane, train, or automobile in the course of
completing their wish.
(Initial
C I :

Ph sician or Primar Caregiver Name:

Address:

Cit : State: Zip:

Phone:
Email:

Does the individual require o gen for air travel? Yes No

T , @ .

W h Rec e Na e

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 W f a L fe e L ab Re ea e
a d
Med ca I f a A a

L R M I A (R
F ): The undersigned ( I or me ) voluntaril agrees to participate in the F
P sponsored b Wish of a Lifetime ( WOL ). In consideration of being permitted b WOL to participate
in WOL Wish Fulfillment Program and the intangible value that I ill gain b participating, and in recognition
of WOL's reliance hereon, I agree to all the terms and conditions set forth in this instrument (this "Release and
Authori ation").

I understand that involvement in the WOL Wish Fulfillment Program entails risk of serious injur or harm,
disabilit , death and/or propert damage. I ackno ledge that an injuries that I sustain ma result from or be
compounded b the actions, omissions, or negligence of WOL, including negligent emergenc response or rescue
operations of WOL. I recogni e that WOL has not undertaken an dut or responsibilit for m safet .
Not ithstanding the risk, I ackno ledge I am voluntaril participating in the WOL Wish Fulfillment Program,
and I hereb illingl and voluntaril accept and assume full responsibilit for all risk of bodil injur , death,
disabilit , and propert damage as a result of and/or in connection ith m participation in the OL
F P .

I hereb surrender an right to seek reimbursement from WOL and its directors, officers, emplo ees, volunteers,
assignees, delegates, and other agents for an injur and/or damages sustained and/or liabilit incurred during
m participation in WOL Wish Fulfillment Program. I hereb e pressl aive and release an and all claims,
no kno n or hereafter kno n, against WOL, and its directors, officers, emplo ees, volunteers, assignees,
delegates and other agents (collectivel , "WOL Releasees"), arising out of or attributable to m participation in
the WOL Wish Fulfillment Program, hether arising out of the ordinar negligence of WOL or an WOL
Releasees or other ise. I covenant not to make or bring an such claim against WOL or an other WOL Releasee,
and forever release and discharge WOL and all other WOL Releasees from liabilit under such claims.
This Release and Authori ation does not e tend to claims or an other liabilities that Colorado la does not
permit to be released b agreement.

I agree to defend, indemnif and hold WOL and all other WOL Releasees harmless from and against an and all
liabilit , damages and claims of an kind, kno n and unkno n, hich ma be connected ith, result from, or
arise out of the consideration, preparation, fulfillment or participation in the WOL Wish Fulfillment Program,
including, but not limited to, claims involving economic loss, illness or medical condition, accidental injur or
death.

I hereb grant WOL permission to obtain all medical information that WOL deems necessar for participation
in the WOL Wish Fulfillment Program. I authori e all healthcare providers, including m primar ph sician, to
provide WOL ith all such information, and agree to sign an medical authori ation forms that are required b
m healthcare providers and/or are deemed necessar for participation in the WOL Wish Fulfillment Program.

I hereb consent to receive medical treatment deemed necessar if I am injured or require medical attention
during m participation in the WOL Wish Fulfillment Program. I understand and agree that I am solel
responsible for all costs related to such medical treatment and an related medical transportation and/or
evacuation. I hereb release, forever discharge, and hold harmless WOL and all WOL Releasees from an claim
based on such treatment or other medical services.

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C : This Agreement contains the entire agreement of the parties ith respect to the subject matter of
this Agreement, and supersedes all prior negotiations, agreements and understandings ith respect thereto. This
Agreement ma onl be amended b a ritten document dul e ecuted b all parties. I have not relied on an
statement, representation, arrant or agreement of WOL or of an other person on WOL's behalf, including
an representations, arranties or agreements arising from statute or other ise in la , e cept for the
representations, arranties or agreements e pressl contained in this Agreement. If an term or provision of
this Agreement is invalid, illegal or unenforceable in an jurisdiction, such invalidit , illegalit or
unenforceabilit ill not affect an other term or provision of this Agreement or invalidate or render
unenforceable such term or provision in an other jurisdiction. WOL ma assign this Agreement and its rights
hereunder, in hole or in part, to an part . This Agreement is binding on and inures to m benefit and the
benefit of WOL and our respective heirs, e ecutors, administrators, legal representatives, successors and
permitted assigns.

I e pressl agree that this Release and Authori ation is intended to be as broad and inclusive as permitted b the
la s of the State of Colorado, and that this Release and Authori ation shall be governed b and interpreted in
accordance ith the la s of the State of Colorado ithout giving effect to an choice or conflict of la provision
or rule ( hether of the State of Colorado or an other jurisdiction). An claim or cause of action arising under
this Agreement ma be brought onl in the federal and state courts located in the Cit and Count of Denver,
Colorado, and I hereb irrevocabl consent to the e clusive jurisdiction of such courts.

Signed Name: ________________________________ Date: _____________________

Printed Name: ________________________________

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 W f a L fe e
P b c Wa e a d Re ea e
WISH OF A LIFETIME, a 501(c)(3) nonprofit organi ation with offices located at 110 16 th St, Suite 406,
Denver, CO 80202 ("WOL"), desires to use and publici e the name, likeness, and other personal characteristics
and private information of the individual named below with a residence at the address set out below ("I" or
"me") for advertising, promotion, and other commercial and business purposes. In e change for the intangible
value I will gain b participating in WOL s publicit programs and other good and valuable consideration, the
receipt and sufficienc of which I hereb acknowledge, I give WOL m permission for such use and publicit
for such purposes, according to the terms and conditions set forth in this Publicit Waiver and Release (this
"Agreement").

I hereb irrevocabl permit, authori e, grant and license WOL and its affiliates, successors and
assigns, and their respective licensees, advertising agencies, promotion agencies and fulfillment
agencies, and the emplo ees, officers, directors and agents of each and all of the foregoing
( Authori ed Persons ), the rights to displa , publicl perform, e hibit, transmit, broadcast,
reproduce, record, photograph, digiti e, modif , alter, edit, adapt, create derivative orks, e ploit,
sell, rent, license, other ise use and permit others to use m name, image, likeness and appearance,
professional and personal biographical information, signature and other personal characteristics and
private information (including medical conditions and other personal health information), and all
materials created b or on behalf of WOL that incorporate an of the foregoing ("Materials") in
perpetuit throughout the universe in an medium or format hatsoever no e isting or hereafter
created, on an platform and for an purpose, including but not limited to advertising, public
relations, publicit , packaging and promotion of WOL and its affiliates and their businesses, products
and services, ithout further consent from or ro alt , pa ment or other compensation to me. I
understand that it is m responsibilit to inform WOL at the time of disclosure if there is an
information I share that I ish to keep confidential. Wish of a Lifetime ill respect the ishes of all
Wish Nominees and their famil members ith regards to the confidentialit of an information if so
requested.

WOL shall be the e clusive o ner of all rights, including cop right, in the Materials. I hereb
irrevocabl transfer, assign and other ise conve to WOL m entire right, title and interest, if an , in
and to the Materials and all cop rights and other intellectual propert rights in the Materials arising
in an jurisdiction throughout the universe in perpetuit , including all registration, rene al and
reversion rights, and the right to sue to enforce such cop rights against infringers. I ackno ledge and
agree that I have no right to revie or approve Materials before the are used b WOL, and that WOL
has no liabilit to me for an editing or alteration of the Materials or for an distortion or other effects
resulting from WOL's editing, alteration, or use of the Materials, or WOL's presentation of me. An
credit or other ackno ledgment of me, if an , shall be determined b WOL in WOL's sole discretion.
WOL has no obligation to create or use the Materials or to e ercise an rights given b this Agreement.

To the fullest e tent permitted b applicable law, I hereb irrevocabl waive all legal and equitable rights
relating to all liabilities, claims, demands, actions, suits, damages and e penses, including but not limited to
claims for cop right or trademark infringement, infringement of moral rights, libel, defamation, invasion of an
rights of privac (including intrusion, false light, public disclosure of private facts and misappropriation of
name or likeness), violation of rights of publicit , ph sical or emotional injur or distress or an similar claim
or cause of action in tort, contract or an other legal theor , now known or hereafter known in an jurisdiction
throughout the world (collectivel , "Claims"), arising directl or indirectl from the Authori ed Persons'
e ercise of their rights under this Agreement or the production, e hibition, e ploitation, advertising, promotion
or other use of the Materials, and whether resulting in whole or in part from the negligence of WOL or an
other person, and I hereb covenant not to make or bring an such Claim against an Authori ed Persons and
forever release and discharge the Authori ed Persons from liabilit under such Claims. I understand that WOL
is rel ing on this Agreement and will incur significant e pense in reliance on this Agreement, and I agree that

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this Agreement cannot be terminated, rescinded or modified, in whole or in part, without a written document
dul e ecuted b both parties.

I represent and warrant to that I have full right, power and authorit to enter into this Agreement and grant the
rights hereunder. I further represent and warrant to WOL that I will provide onl true and correct statements
and other information in connection with this Agreement, and the Authori ed Persons' use of the Materials and
the rights and license granted hereunder do not, and will not, violate an right (including without limitation
cop right, trademark, trade secret, right to privac or right of publicit ) of, or conflict with or violate an
contract with or commitment made to, an person or entit , and that no consent or authori ation from, or an
pa ment to, an third part is required in connection herewith. I agree to defend, indemnif , and hold harmless
the Authori ed Persons from and against all Claims b third parties resulting from m breach or alleged breach
of this Agreement or an of the foregoing representations and warranties.

This Agreement constitutes the sole and entire agreement of the parties with respect to the subject matter
contained herein and supersedes all prior and contemporaneous understandings, agreements, representations
and warranties, both written and oral, with respect to such subject matter. I have not relied on an statement,
representation, warrant or agreement of WOL or of an other person on WOL's behalf, including an
representations, warranties or agreements arising from statute or otherwise in law, e cept for the
representations, warranties or agreements e pressl contained in this Agreement. If an term or provision of
this Agreement is invalid, illegal or unenforceable in an jurisdiction, such invalidit , illegalit or
unenforceabilit will not affect an other term or provision of this Agreement or invalidate or render
unenforceable such term or provision in an other jurisdiction. WOL ma assign this Agreement and its rights
hereunder, in whole or in part, to an part . This Agreement is binding on and inures to m benefit and the
benefit of WOL and our respective heirs, e ecutors, administrators, legal representatives, successors and
permitted assigns. All matters arising out of or relating to this Agreement shall be governed b and construed
in accordance with the internal laws of the State of Colorado without giving effect to an choice or conflict of
law provision or rule (whether of the State of Colorado or an other jurisdiction). An claim or cause of action
arising under this Agreement ma be brought onl in the federal and state courts located in the Cit and Count
of Denver, Colorado, and I hereb irrevocabl consent to the e clusive jurisdiction of such courts.

THIS AGREEMENT PROVIDES WOL WITH YOUR ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER,
AND RELEASE OF LIABILITY, ALLOWING WOL TO PUBLICIZE AND COMMERCIALLY USE YOUR NAME,
LIKENESS, AND OTHER PERSONAL CHARACTERISTICS AND PRIVATE INFORMATION AS SET OUT
ABOVE. BY SIGNING, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTOOD ALL OF THE
TERMS OF THIS AGREEMENT AND THAT YOU ARE GIVING UP SUBSTANTIAL LEGAL RIGHTS.

Signed:
_____________________________
Printed Name:
_____________________________
Address:
_____________________________
_____________________________

Date: ________________________

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G Q :

Minimum age of 65
A Legal Resident or Citi en of the United States of America
Unable to fulfill the ish on our o n
Ph sicall and Ps chologicall able to e perience the ish
Not convicted of a crime
Able to obtain approval from a doctor, if necessar

What Will Not be Granted or Considered:

Financial Assistance (cash pa ment of bills, rent, ta es, etc.)

Housing Assistance (home repair/modification, assistance moving, locating housing, etc.)
Home Furnishings
Technolog (computers, phones, cell phones, tv's)
Medical care or services
Legal Services
Vehicle (purchase, repair, modification)
Potentiall harmful or dangerous ishes
Wishes on behalf of others under 65

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