Refer A Kid

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

To be eligible, the kids 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

Please provide as much information as possible, particularly the kid’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 kid*:

How did you hear about us?:

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

Kid’s Name*:

Address:

City:

State*:

Zip Code:

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

What is the age of the kid?:

Can the kid 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 (If referring a kid, please make sure you tell us the kid’s full name here):

How did you find out about us?*: