Refer a Child

Child's Information

Child's Full Name *

Has the child ever received a wish from any other organization or are you currently working with any other organizations? * ---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.