Refer A Child

Anyone can refer a child to our wish granting program – a family member or friend, nurse, doctor or social worker. Please provide as much information as possible, particularly the child’s full name and parent/guardian contact information. You may also leave your contact information in case we are unable to reach the family. Thank you for your gift of caring.

PLEASE NOTE: There are several required fields in order to facilitate your referral, as indicated by the *asterisk*. If you are unable to fill these fields in, please feel free to call us with your referral, toll-free, at 888-918-9004.

Your Name*:

Relationship to child*:

How did you hear about us?:

Parent or Guardian Name (type 'same' if not different from the name field*:

Child's Name*:

Address:

City:

State*:

Zip Code:

Has the child had a wish granted before by ANY wish granting organization?:

What is the age of the child?:

Can the child communicate his or her wish either verbally, with switches, communication boards, or sign language?
If yes, how?:

Family Phone*:

Your Phone*:

Your Email*:

Comments (If referring a child, please make sure you tell us the child's full name here):

How did you find out about us?*: