Apply for a Wish

		Wishes & More® enhances the life of a child fighting a terminal or life-threatening condition by providing extraordinary experiences including wishes, scholarships, memorials and more.

Isaac Meets WWE Superstar!

Isaac loves wrestling and wanted nothing more than to meet a famous WWF/WWE Superstar!

Please call us to apply for a wish.

Date:	03/14/2010
Should this application be expedited?	Yes No
* Reason for expediting:
WISH CHILD INFORMATION
* Wish Child's First Name:
Wish Child's Middle Name:
* Wish Child's Last Name:
* DOB (m/d/y):	/ /
Gender?	Male Female
* Medical Condition:
Primary Language:
Permanent Street Address:
City:
State:
Zipcode:
Country:
FAMILY INFORMATION
Parent/Legal Guardian:
	Mother Father Other
Street Address:
City:
State:
Zipcode:
Home Telephone:
Work Telephone:
Cell Telephone:
Email Address:
Primary Language(s):
Employer:
Parent/Legal Guardian:
	Mother Father Other
Street Address:
City:
State:
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:
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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961 Hillwind Road

Minneapolis, MN 55432

763.502.1500 (Office)

763.502.4707 (Fax)