Form for Translation

Name of Nominated Child*
First Last
Is this child an ALTERNATE?*
Please only answer yes to this question if advised to do so.
- Yes
- No
Nominator Information
Are you?*
Name of Agency*
Name of Parent/Guardian*
Name of Agency Contact*
First Last
Agency Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent/Guardian Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Contact Number*
Primary Contact Number*
Secondary Contact Number*
Agency Email*
Enter Email Confirm Email
Parent/Guardian Email*
Enter Email Confirm Email
Child Selection Criteria
The child is a Canadian citizen:*
This is a requirement - no exceptions can be made to this criteria.
- Yes
- No
The child has a Canadian long form birth certificate:*
The long form birth certificate has the parents named listed.
- Yes
- No
Are the parents of the child an Air Canada employee?*
- Yes
- No
Has the child been to a Disney or Universal type theme park (including Canada's Wonderland):*
- Yes
- No
The Dreams Take Flight program is NOT to be used as a reward program for schools or agencies. Has the child selected because of a school or agency reward?*
- Yes
- No
Has the child been vaccinated for COVID-19?*
Are you willing to vaccinate your child for COVID-19 should it be required for travel?*
Dreams Take Flight Atlantic recommends all children are vaccinated for COVID-19 but it is not a requirement. Should the government implement COVID-19 vaccine requirements for travel then Dreams Take Flight Atlantic would have to follow the same protocols.
Child Information
Legal FIRST Name (as it appears on the Birth Certificate)*
Legal LAST Name (as it appears on the Birth Certificate)*
Preferred FIRST Name*
Date of Birth*
DD slash MM slash YYYY
What is the child's age on the day of flight? (April 30, 2025)*
What is the child's sex?*
How does the child identify?*
What is the child's pronouns?*
What is the child's culture/ethnicity?*
What area does the child live in?
Please state the area the child lives in.
Child's Address*
We use this information to mail the memory book in the summer. Please make sure the address is accurate and complete. If the address changes before the book is received, you need to advise us of this change.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What school does the child attend?*
Birth Certificate
The long form birth certificate with the parent's names listed is required.
Do the parents/guardians have the long form birth certificate?*
***The long form birth certificate is required*** If you do not have it, please order it right away as it can take up to 3 months to receive.
Birth Certificate Registration Number
Issuing Province / Territory
Upload scanned copy of the Birth Certificate
Drop files here or

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 50 MB.
Provincial Medical Card
Health Card Number*
Health Card Expiry Date*
Issuing Province / Territory*
Child Particulars
If there are any major changes to the child particulars such as dyed hair, please inform us right away.
Eye Colour*
Hair Colour*
Height (feet & inches)*
Weight (in pounds)*
Birth marks, scars, etc*
Wears Glasses*
- Yes
- No
Photo of Child
Please upload a photo (head shot) of the child. This is used for safety purposes during the trip.
Upload Photo Here*
Max. file size: 50 MB.
Child Clothing
T-shirt Size*
Other T-Shirt Size*
Shorts Size*
Other Shorts Size*
Hoodie Size*
Other Hoodies Size*
Shoe Size*
Legal Parent or Guardian Information
Custody Status of Child*
Do you have legal documents?*
Define 'Other'*
Relationship to the child*
If two parents are listed on the birth certificate and you do not have legal documents to attach - both parents will be required to sign consent.
Upload any documents pertinent to the child's custody status.
Max. file size: 50 MB.
This could include sole or joint custody court orders, temporary or permanent care orders, obituaries or death certificates of deceased parents, etc...
Parent/Guardian's Legal Name*
2nd Parent/Guardian's Legal Name*
Parent/Guardian Primary Contact Number*
Parent/Guardian Secondary Contact Number
Parent/Guardian Email Address*
Address of Parent / Guardian*
Street Address Address Line 2 City Province Postal Code
Emergency/Alternate Contact Information
This information must be valid and available from the time when children are dropped off at the airport in the morning and until the children are picked up in the evening.
Name of Emergency Contact*
First Last
Relationship to Child*
Emergency Contact Primary Phone Number*
Emergency Contact Secondary Phone Number
*Very Important: if any of the above contact information changes from now until the day of flight, it is the parent or guardian's responsibility to keep the agency updated. Failure to do so could result in the removal of the child from the flight!
Child Medical Declaration
Does the Child have a pre-existing medical condition?*
- Yes
- No
If YES, does the child have medical coverage which covers travel to the USA?*
- Yes
- No
If YES to either of the above please provide details*
Does the Child have any allergies?*
- Yes
- No
If YES, please explain*
Does the Child have any special dietary requirements?*
- Yes
- No
If YES, please explain*
Does the Child have any special needs (include behavioral or phobias)?*
- Yes
- No
If YES, please explain*
Is the Child taking any medication?*
- Yes
- No
If YES, please provide name, dose, frequency & time*
Does the Child require a wheelchair?*
- Yes
- No
Child Insurance Declaration
If YES is the answer to any question below, please ensure to provide more information in the text box provided right after the question.
Has your child ever required or received medical treatment or prescription medications for heart / cardiovascular condition or a stroke / cerebral vascular condition or an aneurysm?*
- Yes
- No
Please provide more details*
In the past 12 months (6 months for high blood pressure) has your child received any new prescription medication or new medical treatment for any medical condition?*
- Yes
- No
Please provide more details*
In the past 12 months (6 months for high blood pressure) has your child had any prescription medication changed, reduced, stopped or increased for any medical condition? (not including a change between brand name & generic brand)*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had lung/respiratory condition?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had diabetes which is controlled by diet, medication, or with insulin?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had any test, investigation, or surgery recommended but not yet completed?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Cancer or Leukemia?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had blood disorder?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Kidney disorder requiring dialysis or Liver disorder?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Circulatory disorder of the arteries or veins?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Pancreatic disorder?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Muscle, Bone, Joint disorder (not arthritis)?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Stomach or Bowel disorder?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Urinary disorder?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Parkinson's disease or Seizures?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had High Blood Pressure (Hypertension)?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had Prostate disorder?*
- Yes
- No
Please provide more details*
In the past 5 years, has your child required or received medical treatment or taken prescription medication for or had any other pre-existing condition currently requiring medication?*
- Yes
- No
Please provide more details*
Anything else we should know?
Additional Child Information
Does your child require assistance to sit upright and walk?*
- Yes
- No
Please provide more details*
Does your child have problems with bowel or urinary functions?*
- Yes
- No
Please provide more details*
Does your child require supplemental oxygen?*
- Yes
- No
Please provide more details*
Does your child require a feeding tube?*
- Yes
- No
Please provide more details*
Does your child use any special devices which are required at all times?*
- Yes
- No
Please provide more details*
If you have answered YES to any of the above, is there anything else we should know?
Sports Wheels
Sports Wheels will be sponsoring two Dreams Take Flight children to play sports if they are interested. Please provide the below information to help them choose the two children. Please note, you will only be contacted if the child is selected.
Is this child interested in playing sports?
What sports is the child interested in playing?
Anything else?
Extra child information:
If there is anything else Dreams Take Flight Atlantic should know about the child to ensure a fun and safe day that has not already been covered or if you would just like to provide additional detail towards anything that has already been covered, please enter it here.
Name of Person Submitting*
Initials of Person Submitting*
Date of Signing*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Nominator Information

Child Selection Criteria

Child Information

Birth Certificate

The long form birth certificate is required If you do not have it, please order it right away as it can take up to 3 months to receive.

Provincial Medical Card

Child Particulars

Photo of Child

Child Clothing

Legal Parent or Guardian Information

Emergency/Alternate Contact Information

Child Medical Declaration

Child Insurance Declaration

Additional Child Information

Sports Wheels

Anything else?

Dreams Take Flight | Atlantic

Give

About

Medical Release

Nominator Information

Child Selection Criteria

Child Information

Birth Certificate

***The long form birth certificate is required*** If you do not have it, please order it right away as it can take up to 3 months to receive.

Provincial Medical Card

Child Particulars

Photo of Child

Child Clothing

Legal Parent or Guardian Information

Emergency/Alternate Contact Information

Child Medical Declaration

Child Insurance Declaration

Additional Child Information

Sports Wheels

Anything else?

Dreams Take Flight | Atlantic

Give

About

Medical Release

The long form birth certificate is required If you do not have it, please order it right away as it can take up to 3 months to receive.