Referral Form

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 and/or terminal illness
  • The child’s illness must be verified by a licensed 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 eligible for a wish through The Rainbow Connection. Please fill out the referral information below and submit it to our office.

Child's Information

Child's Name (first & last)*

Child's Birthdate

Parent(s) Guardian(s)*

Phone number (with area code)*
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Street Address*

City*

State*

Street Address*

Child's Physician (if known)

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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