Partner Facility Signup

The Hero of the Month Wish Program was designed to help little heroes who have had to face some of life’s unfortunate experiences.

These children do not have life-threatening illnesses, but rather face some very sad or extraordinary circumstances. Participating facilities include children hospitals, rehab centers, homeless shelters, burn centers, domestic violence shelters, foster child facilities, child advocacy centers and other faculties that cater to the needs of children.

The child must meet the following criteria:

  • be between the ages of 3-18
  • has not received a wish from another wish granting organization
  • has overcome an obstacle/situation despite the odds against them that could be described as heroic

Part 1: Contact Information

Facility Name*:

Primary Contact*:

Phone*:

Fax*:

Email*:

Mailing Address*:

Part 2: Facility Information

1. Our facility is a*:
HospitalRehab FacilityBurn CenterShelterOther

2. Approximately, how many children (ages 3- 18 years old) receive services at your facility (in a year)?*:

3. How many pediatric beds do you have? Age?*:

4. Do you have additional pediatric clinics at this location? How many?*:

5. Approximately how many children do they see a month (per clinic)?*:

6. How many playrooms do you have? What age groups?*:

7. What game systems do you have at your facility? (For example: computers, Playstations, Xboxes, etc.)*:

8. Do you have a secure room/storage area to keep toys?*:

9. How long do the children/families stay?*:

10. Comments/Suggestions?

How did you hear about us?:

The completion of this questionnaire does not guarantee acceptance into the Hero of the Month Program.