If you have an account please sign in to continue
An account is a great way to keep track and manage your activity within our site.
If you have already entered your email address and created a password while completing a form within our site, it is likely you have an account. You should have received an email to confirm this.
⬅ back to program information
Are you applying on behalf of someone? *
No - I am the recipient
Yes - I am applying on behalf of someone living with MND
If yes, what is your name and relationship to the person living with MND?
Recipient First Name *
Recipient Last Name *
Recipient Date of Birth *
Is the recipient registered to receive services from MND Victoria? *
MND Advisor/Support Coordinator Name
Recipient Street Address *
What is your Bucket List Wish and why? *
Are there any specific care or accessibility requirements needed to fulfill this wish?
What is the estimated cost of your Bucket List Wish? *
Do you have a time frame of when you would like to have your wish completed by? *
Within 3 months
In the next 3 - 6 months
Within the next year
Is there anything else we need to know about?
I acknowledge no promises have been made to me by MND Victoria, regarding the requested wish. *
I have read and understood MND Victoria’s Bucket List Wish program eligibility criteria for wishes. *
I understand all wish requests are subject to approval by MND Victoria and must meet all existing conditions and restrictions. *
I understand due to limited pool of funds, unfortunately MND Victoria may not be able to grant every application. *
I declare that I, or the recipient has been made aware of that fact and of the contents of the Privacy Statement www.mnd.org.au/page/2/privacy and consent to the collection, use, and disclosure of personal information in line with the Privacy Statement. *
I agree that information collected on this form will be recorded on an electronic client record in MND Victoria’s client management system. *
I am aware MND Victoria may want to capture the granted wish to be used in publications, social media and publicly.
I am aware that third party services used to fulfill this wish may want to publicise their involvement.
For further information contact our friendly team, at firstname.lastname@example.org (03) 9830 2122
Please enter a valid email address
We acknowledge Aboriginal and Torres Strait Islander peoples as the Traditional Custodians of the lands in which we live, work, and learn. We recognise and respect the enduring relationship they have with their lands and waters, and we pay our respects to Elders past, present, and emerging.
© 2022 MND Victoria