Child Referral Form

If you are the parent or legal guardian of a child who has reached the age of 2 1/2 and is under the age of 18 who may be eligible to receive a wish, please fill out the form below. Your information will be forwarded to your local chapter, and you will be contacted shortly. Children may also refer themselves or be referred by a medical professional. To refer a child who resides outside of the United States and its territories, contact Make-A-Wish Foundation® International.

* Indicates Required Field

*  Your First Name:
* Your Last Name:
* Relationship to child:	Self Parent/Legal Guardian Medical Professional
* E-mail:
* Phone Number:
* Address 1:
Address 2:
* City:
* State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
* Zip Code:
Comments:

© 2007 Make-A-Wish Foundation^® of Middle Tennessee