Refer A Child

Every Wish Experience Begins with a Referral

Every child deserves to have a one-of-a-kind and life-changing experience. To ensure the best quality of wishes, there’s a standard process Make-A-Wish follows.

Who can refer a child to Make-A-Wish? Eligibility Privacy Policy

REFER A CHILD ONLINE FORM

Your First Name*
Your Last Name
Your Phone*
Email*
Your relationship to the child you wish to refer:*
- Parent/Guardian
- Medical Professional
- Self (potential wish child)
Please note: Out of respect for the privacy of the children and families we serve, children must be referred by specific individuals (see list above). If you do not fall into one of these options, please ask the child's family to visit our website, contact their local chapter, or contact our national office at [email protected] or 1-888-822-9474.
Child's Name*
Child's Date of Birth*
Gender*
- Male
- Female
- Self-describe
Gender(Self-describe)
Child's Medical Condition*
Year of diagnosis
Physician’s name*
Child’s treatment hospital/clinic*
Has this child had a wish granted by any other organization?*
- Yes
- No
If yes, name of organization*
Child’s Address*
Street Address City Province Postal Code
Child's Family Phone*
Child's Family Email*
Parent/guardian 1 name*
Parent/guardian 1 email*
Parent/guardian 1 phone*
Parent/guardian 2 name
Parent/guardian 2 email
Parent/guardian 2 phone
Where did you learn about Make-A-Wish?
Additional Comments*
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