Wish Process

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Wish Referral Form

Please read the Frequently Asked Questions before completing the Wish Referral Form.  You can submit the referral form below or print and mail/fax the referral form to the office.  Our contact information can be found here.  Please don't hesitate to call us with questions.

Date:	02/04/2012
Should this application be expedited?	Yes No
* Reason for expediting:
WISH CHILD INFORMATION
* Name of Who is Filling This Out:
* Your Relationship to Wish Child:
* Wish Child's First Name:
Wish Child's Middle Name:
* Wish Child's Last Name:
* DOB (m/d/y):	1 2 3 4 5 6 7 8 9 10 11 12 / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Gender?	Male Female
* Medical Condition:
Primary Language:
Permanent Street Address:
City:
State:	AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zipcode:
Country:
FAMILY INFORMATION
Parent/Legal Guardian:
	Mother Father Other
Street Address:
City:
State:	AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zipcode:
Home Telephone:
Work Telephone:
Cell Telephone:
Email Address:
Primary Language(s):
Employer:
Parent/Legal Guardian:
	Mother Father Other
Street Address:
City:
State:	AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zipcode:
Home Telephone:
Work Telephone:
Cell Telephone:
Email Address:
Primary Language(s):
Employer:
Siblings Name & Age:
PHYSICIAN AND MEDICAL INFORMATION
Physician Name:
Hospital/Treatment Facility:
Office Telephone:
Fax:
Street Address:
City:
State:	AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zipcode:
WISH INFORMATION
Has the child ever received a wish from Wishes & More® or another wish granting organization?	Yes No
Does the child reside with both biological parents?	Yes No * If no, additional paperwork may be necessary.
Is the child aware of his or her condition?	Yes No
Is the child able to verbalize his or her wish?	Yes No
If no, how does the child communicate?
Does the child have developmental delays?	Yes No
If yes, what is developmental age?
NOTE: Wishes & More® does not solicit wish recipients as the family may not be ready to accept Wishes & More® as part of their lives at this time. Therefore, please respond to the next statement: The parent/guardian is aware that you are completing this form on their behalf. Yes No
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