Web Site 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 No 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