Refer a Child Form

Please fill out the following as completely as possible.

Child must have a life-threatening disorder.

The child must be between the ages of birth up through, and including age 20.

The child must never have had a "wish" with any other wish-granting organization.

Child's First Name

Child's Last Name

Child's Date of Birth

Child's Age

Had the child ever had a wish with another Wish-Granting Organization?

Yes

Mother's Full Name

Father's Full Name

Parent/Guardian's Street Address

City/State

Zip Code

Home Phone

Cell Phone

Parent Email Address

Medical Information

Child's Illness

Child's Medical Specialist

Medical Specialist's Phone Number

Medical Specialist's Fax Number

Specialist's Street Address

City/State

Zip