Wish Referral: Form for Families

Make-A-Wish Canada grants wishes to children who are between the ages of 3-17, who have not received a prior wish from any wish granting organization, who have a critical illness that is in a life-threatening stage (or with extreme long-term complications), who meet one or more of the following eligibility criteria:

Children whose current medical condition requires high-risk therapy to survive
Children who are dependent on technology to survive (e.g., tracheostomy; chronic assisted ventilation; transfusion-dependence)
Children who have chronic conditions that demonstrate extreme long-term complications
Children who are at high risk of sudden death

Please ensure you have read our wish eligibility criteria before submitting a referral. If you have any questions about the wish referral process, please contact us at referachild@makeawish.ca or 1.888.822.9474.

Make-A-Wish Canada is a bilingual organization and have staff that can fully serve wish families in both English and French.

Preliminary Information

Your relationship to the child you are referring:*

Parent or Legal Guardian

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 (parent or legal guardian, themselves, or a healthcare professional). If you do not fall into one of these options, please ask the child’s family to visit our website or contact our national office at referachild@makeawish.ca or 1-888-822-9474.

Is the child you are referring currently between the ages of 3 and 17 years old?*

Yes

Has this child had a wish granted by any other organization?*

Yes

Your Contact Information*

First name Last name

Your Email*

Information on Referred Child

Child's Name*

First Name Last Name

Date of birth*

Age*

Gender*

Male

Female

Self-describe

Child's Preferred Pronouns

Self-describe*

Child’s Primary Residence*

Street Address City Province / Territory Postal Code

Was the child born in Canada?*

Yes

Children do not need to be born in Canada or hold citizenship to qualify for a wish. Eligibility is based on medical criteria and current residency in Canada.

What is your family’s primary language(s)?*

English

French

Other

If other, please specify:*

If your family’s primary language is not English or French, do you have someone who can assist with translation? Please provide their first name, last name, email address and phone number.*

Parent(s)/Legal Guardian(s) Information

Parent/Legal Guardian #1 name*

First Name Last Name

Relationship to Child:*

Parent/Legal guardian #1 email**

Parent/Legal guardian #1 phone*

Parent/Legal Guardian #1 Address – same as wish child?*

Yes

Parent/Legal Guardian #1 Address*

Street Address Address Line 2 City Province / Territory Postal Code Country

Parent/Legal Guardian #2 Name

First Name Last Name

Relationship to Child:

Parent/Legal Guardian #2 Email

Parent/Legal Guardian #2 Phone

Parent/Legal Guardian #2 Address – same as wish child?

Yes

Parent/Legal Guardian #2 Address

Street Address Address Line 2 City Province / Territory Postal Code Country

Who has legal custody of the child?*

Both parents, same home

Shared custody (separate residences)

Parent/Legal guardian #1 has sole custody

Parent/Legal guardian #2 has sole custody

Other

Child's Medical Information

Child's Diagnosis*

Date of Diagnosis*

Physician’s Name*

First Last

Physician's Phone Number*

Physician's Email

Province or territory where the child is being treated

Child's hospital/clinic in Alberta*

Child's hospital/clinic in British Columbia*

Child's hospital/clinic in Manitoba*

Child's hospital/clinic in New Brunswick*

Child's hospital/clinic in Newfoundland & Labrador*

Child's hospital/clinic in Nova Scotia*

Child's hospital/clinic in Ontario*

Child's hospital/clinic in Prince Edward Island*

Child's hospital/clinic in Quebec*

Child's hospital/clinic in Saskatchewan*

Please specify the child's hospital/clinic:*

Additional Comments (Max 500 Characters)

We're sorry

We’re sorry, but to submit a wish referral, the potential wish child has to be between the ages of 3 and 17 years and not have had a wish granted by any other organization.

If you have any questions, please contact us at referachild@makeawish.ca.