Dialysis Fund Application

Dialysis Guest Information

Legal First Name(Required)

Legal Last Name(Required)

Nickname / Preferred Name

Date of Birth(Required)

Gender (As Listed on Travel Documents)(Required)

Cell Phone #(Required)

Home Phone #(Required)

Work Phone #

Email(Required)

Street Address(Required)

City(Required)

Country(Required)

State(Required)

Zip Code(Required)

Citizenship(Required)

Unisex T-Shirt Size(Required)

If yes, please fill out the Dialysis Guest Companion section below.

Dialysis Guest Companion Information

Legal First Name(Required)

Legal Last Name(Required)

Nickname / Preferred Name

Date of Birth(Required)

Gender (As Listed on Travel Documents)(Required)

Cell Phone #(Required)

Home Phone #(Required)

Work Phone #

Email(Required)

Street Address(Required)

City(Required)

Country(Required)

State(Required)

Zip Code(Required)

Citizenship(Required)

Unisex T-Shirt Size(Required)

Describe the relationship between you and your companion? (Example: Friend, Family Member, Spouse, Partner, Co-Worker, Caretaker, etc.)(Required)

Dialysis Information

Name of Dialysis Unit(Required)

Dialysis Unit Phone #(Required)

Dialysis Unit Street Address(Required)

City(Required)

Country(Required)

State(Required)

Zip Code(Required)

Name of Social Worker(Required)

Social Worker Cell Phone #(Required)

Social Worker Email(Required)

1. How long have you been on hemodialysis? (Example: Since August 2023)(Required)

4. What days of the week do you receive dialysis treatments? (Example: Mon, Wed, Fri)(Required)

5. What time of the day do you receive dialysis treatments? (Example: 1:00 PM – 4:00 PM)(Required)

If yes or occasionally, please explain:

If yes, please specify:

Additional Questions

If yes, what year?

2. How did you hear about the High Seas Rally Dialysis Fund Program?(Required)

If yes, please specify:

If no, please specify:

7. Is there anything else you would like us to be aware of?

CAPTCHA

Please carefully review the information provided on the Dialysis Fund Application for accuracy before submitting. Incomplete applications or those applications containing false information will not be considered. Thank you!

Name

This field is for validation purposes and should be left unchanged.

October 26th – November 2nd, 2024Tampa • Bimini • Freeport • Nassau • CocoCayRoyal Caribbean’s Radiance of the Seas