Refer A Child

Anyone can refer a child to our wish granting program – a family member or friend, nurse, doctor or social worker.

To be eligible, the child must meet these criteria as determined by their physician:

  • Diagnosed with a life-threatening condition, meaning a progressive, degenerative, or malignant condition that is placing the child’s life in jeopardy
  • Between the ages of 3 and 18
  • Has not received a wish from another wish-granting organization
  • Able to communicate, verbally or non-verbally, with switches, communication boards, or sign language

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*:

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*: (By providing your email you agree to receive future communication from Kids Wish Network))

Comments (Tell us about the child and their illness):

How did you find out about us?*:

What did you search?*
Which event?*
Which Healthcare provider?*
What program?*
Explain:*