Refer a child

Our network of advocates, donors and friends help us identify Indiana children who are deserving of a wish. If you have a child or know of one who is facing a life-threatening illness, please fill out a form to tell us more about that child.

Family or friend Medical professional

Referral by Family or Friend

If you have or know of a child in need, please fill out the form below to have their wish considered.

Your Information

Name *

First

Last

Email *

Phone Number *

Referring Company

Parent/Guardian Full Name *

Parent Email *

Child/Parent/Guardian Phone Number

Child's Information

Child's Name *

First

Last

Age *

Date of birth *

Child's Address *

City *

State

Zip Code *

Please describe the child's illness *

Physician's Name

Physician's Phone Number

Physician's Fax Number

Doctor's Phone Number

Has your child ever applied for / had a wish granted? *

Refer a Child

Referral by Family or Friend

Your Information

Child's Information

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