Refer A Child

In your community, the opportunity may arise where you meet a special child that could be referred to our organization for a wish. In order to qualify for a wish, the following criteria must be met:

  • The child must be between the ages of 2 1/2–18 years
  • The child must reside in the state of Michigan
  • The child must be diagnosed with a life-threatening illness. The Rainbow Connection will verify the illness with the child’s physician.
  • The child must not have received a wish from any other organization

If you know of a child that meets the criteria listed above, he/she may be entitled for a wish through The Rainbow Connection. Please fill out the referral information below. To complete the form press send and we will be in contact with you.

 

Child's Information

Child's Name (first & last)*

Has the child ever received a wish from any other organization?

Child's Birthdate

Parent(s) Guardian(s)*

Phone number (with area code)*
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Street Address*

City*

State*

Zip Code*

Child's Physician (if known)

Physician phone number (with area code)
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Physician fax number (with area code)
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Child's Illness (if known)

Hospital Child Is Being Treated At (if applicable)

Family's Social Worker (if applicable)

Your Information

Your Name*

Relationship*

Your Phone number (with area code)*
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Your Email*

Please let us know if there is anything else you would like to tell us.

Please type the characters you see in the box below:
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