Child's Information Child's Full Name * Has the child ever received a wish from any other organization? * ---NoYesI don't know Child's Birthdate * Child's Gender * ---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 Information Your Name * Relationship * Your Phone Number (with area code) * Your Email * Please let us know if there is anything else you would like to tell us.
