Facility Dream Flight Request

This application is for senior care communities. If you are a parent company interested in honoring residents in multiple communities, please forward this link to the individual communities. Each community must apply individually.

All fields are required.

Full Name of Senior Care Facility ^*

Number of Flyers ^*

Facility Info:

Address ^*

City ^*

State ^*

Zip Code ^*

Facility Phone ^*

Full name of Management Company ^*

Is your organization a member of the following organization(s)? Please select all that apply:

AHCA/NCAL

Argentum

Leading Age

Facility Contact:

First Name ^*

Last Name ^*

Personal Cell ^*

Email ^*

Type of Facility:

Independent Living ^*

Assisted Living ^*

Memory Care ^*

Social Handles

Facebook (If known)

Twiter (If known)

Instagram (If known)

Will you be contacting the media? ^*

Will you be inviting other facilities to share your day (e.g., sister facilities)? ^*

Will you invite family and friends? ^*

Do you plan to invite the local community to participate and/or attend the event? Please describe.

Who would accompany and remain with your residents during the event?

A.D./E.C. ^*

Administration ^*

Nurse or other Medical Staff ^*

Which, if any, of the following would you be able to provide for the pilot & ground crew (2 people)?

Overnight Accommodations ^*

Transportation ^*

Meals ^*

Does your community have a PR/Marketing representative?

PR Representative ^*

PR Rep Name

PR Rep Phone

PR Rep Email

Send me a copy

^* These fields are required.