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 Date of Birth

Child's Last Name

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

Home Phone

State

Cell Phone

Zip Code

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