Wish Request Form

For a Wish outing, please fill out the form and send it back to us. A representative from Keshet Hamishalot Foundation will be in touch as soon as possible. A Wish trip can only take place in Israel.

Who is allegeable to make a Wish trip?

To apply:

Fill out the following form clearly– with attention to the various details.
After filing and signing the online form -please send in a separate email to mykeshetm@gmail.com attached the following:
An up-dated letter from the treating physician with all relevant information; including current medical status, description of the illness, medical treatment given to date. The physician should include his/hers approval and the necessary items needed to make the Wish outing come true. For example, an ambulance, wheelchair, oxygen, etc.
Attach a photo of the patient’s I.D. card

1. All requests are confidential. A wish coordinator will be in contact as soon as possible.

2. Patient accompaniment:

The patient must be accompanied by an adult of their choice (over 18) during the outing.

Resuscitation:

A Travel-Wish is designed for the severely ill – those whose lives are threatened. There is always a possibility (however slight) that the patient’s situation will deteriorate during the outing.
It is important to note that we do not perform resuscitation.
In cases where there is a decline in the patients’ situation, the attendant, who is assigned by Keshet Hamishalot Foundation will call for a medical responder to diagnose and administer proper treatment.

The patient must sign a statement called section-B attached to the section-A. A medical team member or relative must verify, in writing, that the patient was clear-minded while signing the document.

Short description of your Wish:

Preferred day of the week:

Accompaniment: who will join?

How many children will be participating in this outing (0-18)?

How did you hear about us?

Details of the patient:

Current medical status. Please include the primary disease.

Medical equipment required:

Hospital name Department hospice

In a non hospital setting is there access to the patient’s home by elevator?

yes no

Patient’s pick up address

Details of the contact person and companion of the patient on the Wish trip with whom we can coordinate the Wish trip details.

Relationship to the patient

Primary doctor's details:

Medical license number

אלבום אחד במתנה

One photo album as a gift

Keshet Hamishalot offers travel wishes that often include many unforgettable and touching moments, bringing loved ones together.

The outing is documented by the Foundations volunteer-photographers and is presented to the family as a gift. This gift encompasses all the memories, challenging
as they may be, to remain with you forever.

Check the box for your agreement.

I am interested to receive photos of the Wish trip and receive one album as a gift from the Foundation.

I give my consent to film or take photos of the event and use it in the Foundation's publications, advertising or other media activities, thus contributing to the Foundation's activities and awareness.

Section A – Keshet Hamishalot Foundation Statement Form

I hereby declare, by my signature, that I was fully informed and advised of the conditions of make a wish come true foundation:

1. I am aware that Keshet Hamishalot Foundation is an organization that specializes in fulfilling travel wishes for terminally ill people. To remove all doubt, I am aware that the Foundation is not committed to providing medical supervision of any kind.
2. I am aware that Keshet Hamishalot Foundation hires a private ambulance (a private mobile vehicle for transporting the disabled and ill) as needed for my Wish to come true.
3. I am aware that a trip involving Keshet Hamishalot Foundation includes: An ambulance driver (medic) if required and a trained volunteer from the Foundation who is solely there to help make your wish come true.
4. I am aware that Keshet Hamishalot Foundation is not involved in any medical or paramedical services, as a routine or in an emergency.
5. I am aware that I am required to provide one adult companion 18 yrs of age and above, until the event is concluded.
6. I am aware that Keshet Hamishalot Foundation does not provide any pharmaceutical treatment of any kind, including pain killers and/or any medication to control nausea. To remove doubt, I declare that I understand that all medical treatment during the event will be administered independently or by my companion and with medicine in my possession, provided by a licensed doctor.
7. I am aware that during the event and depending on my medical condition, there is a possibility of the need to use an oxygen tank by face mask.
8. I am aware that due to my medical condition, the ambulance transportation provided by Keshet Hamishalot Foundation may involve medical risks or changes, decline, and/or other ramifications. I understand that Keshet Hamishalot Foundation is not responsible, directly or indirectly, for any health deterioration or damages that occur. I will have no claims or demands towards Keshet Hamishalot Foundation.
9. I am aware that there is a possibility (even though remote) that my medical condition may change during my Wish fulfillment. In that case, the Foundation’s team or my escort will contact “Magen David Adom” and order an intensive care unit/ambulance for administering medical treatment.
10. I am aware that Keshet Hamishalot Foundation does not carry responsibility, direct or indirect, for treatment provided by “Magen David Adom.”
11. I am aware that Keshet Hamishalot Foundation will not be responsible for the expenses due to the need involved by calling Magen David Adom. I acknowledge that all costs, commitments, or finances will be taken care of by me. I guarantee that all expenses issued to Keshet Hamishalot Foundation for medical services from any provider will be covered by me and will be my responsibility.
12. I am aware that if I want additional medical supervision during my travel wish, sourcing and paying for such services is my own responsibility. To remove all doubt, I declare that Keshet Hamishalot Foundation does not hold any responsibility, directly or indirectly, for services and actions (medical or other) provided by the accompanying representative.
13. I am aware that Keshet Hamishalot Foundation is not obligated to fulfill all Wishes or applications, even if they meet the set criteria. I am aware that at every step, Keshet Hamishalot Foundation can withdraw, delay, and/or cancel their services at their

I hereby declare that with my signature, I remove all claims or demands to Keshet Hamishalot Foundation and/or to any of those involved in the fulfillment of the Wish trip. I also declare that I release Keshet Hamishalot Foundation from all responsibility from all possible physical or emotional deterioration of the Patient’s medical condition that might occur during the Wish trip.

I agree to receive a newsletter from Keshet Hamishalot

"The Rainbow of Questions Association" temporarily stops accepting requests for questions in order to upgrade the organization's system and its volunteers. You can leave us a message at info@keshet-hamishalot.org.il Requests for wishes will be accepted again in early 2023

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