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Refer a Child – Online Application

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Refer a Child – Online Application

To Refer a Child, please complete the form below.

We will respond within one business day to your application. If you do not receive a phone call or email from our staff within that timeframe, please call us (763-502-1500).

Date form completed*
MM slash DD slash YYYY
Should this form be expedited?*
- Yes
- No
If yes, state reason.
Wish Child's Full Name*
Wish Child's Nickname
Wish Child's Date of Birth*
MM slash DD slash YYYY
Wish Child's Gender*
- Female
- Male
Wish Child's Medical Condition*
Wish Child's Current School
Wish Child's Cell Phone
Wish Child's Email Address
Caringbridge Site (if applicable)
Wish Child's Permanent Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
County (associated with permanent address)*
Wish Child's Current Address (if different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Wish Child Language*
1. Parent / Guardian Name*
First Last
1. Parent / Guardian Address (if different from wish child address above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
1. Parent / Guardian Home Phone
1. Parent / Guardian Place of Employment & Job Title*
1. Parent / Guardian Work Phone
1. Parent / Guardian Cell Phone*
1. Parent / Guardian Email*
1. Parent / Guardian Language*
1. Parent / Guardian Military Service
- Veteran
- Active Service
- In-active Service
2. Parent / Guardian Name
First Last
2. Parent / Guardian Address (if different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
2. Parent / Guardian Home Phone
2. Parent / Guardian Place of Employment & Job Title
2. Parent / Guardian Work Phone
2. Parent / Guardian Cell Phone
2. Parent / Guardian Email
2. Parent / Guardian Language
2. Parent / Guardian Military Service
- Veteran
- Active Service
- In-active Service
Preferred Contact Person*
Preferred Contact Method*
- Phone
- Email
- Text
Sibling name(s) and DOB*
Physician Name*
First Last
Physician email address
Hospital / Treatment Facility*
Office Phone*
Office Fax
Office Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Social Worker Name
First Last
Social Worker Phone
Social Worker Email
Social Worker Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Has the wish child received a wish from Wishes & More or any other wish-granting organization?*
- Yes
- No
Is the child aware of their condition?*
- Yes
- No
Does child reside with both legal guardians? (If no, additional paperwork may be needed.)*
- Yes
- No
Is the child able to verbalize his/her wish?*
- Yes
- No
If no, how does the child communicate?
Does the child have development delays?*
- Yes
- No
If yes, what is developmental age?
Wishes & More does not solicit wish recipients as the family may not be ready to accept Wishes & More as a 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
Name of person completing this form*
First Last
Relationship to the wish child*
Phone number (of person completing form)*
Email Address (of person completing form)*
Comments
This field is for validation purposes and should be left unchanged.

Home
Our Kids
Refer A Child
What We Do
Events
How To Help
About Us
Contact Us

* Office: 763.502.1500 | Fax: 763.502.4707

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Home
Our Kids
Refer A Child
What We Do
Events
How To Help
About Us
Contact Us

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Wishes & More®

961 Hillwind Road
Minneapolis, MN 55432
763.502.1500 (Office)
763.502.4707 (Fax)
[email protected]

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