Refer a Child

Child's Full Name *

Has the child ever received a wish from any other organization or are you currently working with any other organizations? * —Please choose an option—NoYesI don't know

Child's Birthdate *

Child's Gender * —Please choose an option—MaleFemale

Parent(s) Guardian(s) *

Phone Number (with area code) *

Street Address *

City *

State *

Zip Code *

Child's Physician (if known)

Physician phone number (with area code)

Physician fax number (with area code)

Child's Illness (if known)

Hospital Child Is Being Treated At (if applicable)

Family's Social Worker (if applicable)

Your Name *

Relationship *

Your Phone Number (with area code) *

Your Email *