Wish Child Application

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Please take a few minutes to complete the following wish application. All applications are screened by our Medical Review Committee, and families will be notified upon decision. Indiana Wish reserves the right to refuse a wish that is not within our power to grant, or if the attending physician deems it is not in the best interest of the child. This application will be retained on file for one (1) year.

WISH CHILD'S INFORMATION

Legal Full Name of Child *

First

Middle

Last

Age at time of application *

Date of Birth *

Sex of Child *

Male
Female

T-Shirt Size *

Youth
Adult

Size *

Address Child Resides *

Address Line 1

Address Line 2

City

State

Zip Code

MEDICAL INFORMATION

Type of Illness *

Attending Physician *

Physician's Phone # *

Physician's Fax # *

Have you ever applied for or had a wish granted? *

Yes, Wish Granted
Yes, but denied or wish was not granted
No

If yes, includes dates & agencies

What Wish does the child request? *

You can list up to three (3) ideas

PARENT / GUARDIAN INFORMATION

Legal Name of Mother / Guardian *

First

Last

Date of Birth for Mother / Guardian *

Mother / Guardian Cell Phone # *

Mother's / Guardian's Email *

Mother's / Guardian's Driver's License # *

Mother's / Guardian's Driver's License Expiration Date *

Mother / Guardian T-Shirt Size *

Legal Name of Father / Guardian *

First

Last

Date of Birth for Father / Guardian *

Father / Guardian Cell Phone # *

Father / Guardian's Email *

Father / Guardian Driver's License # *

Father / Guardian Driver's License Expiration Date *

Father / Guardian T-Shirt Size *

Single Parent? *

SIBLING INFORMATION

No siblings? Skip down to submit.

Single Line Text

Legal Full Name of Sibling #1

First

Last

Age at time of application of sibling #1

Date of Birth of Sibling #1

Sex of Sibling #1

Male
Female

T-Shirt Size of Sibling #1

Youth
Adult

T-Shirt Size Sibling #1

Legal Full Name of Sibling #2

First

Last

Age at time of application of sibling #2

Date of Birth of Sibling #2

Sex of Sibling #2

Male
Female

T-Shirt Size of Sibling #2

Youth
Adult

T-Shirt Size Sibling #2

Legal Full Name of Sibling #3

First

Last

Age at time of application of sibling #3

Date of Birth of Sibling #3

Sex of Sibling #3

Male
Female

T-Shirt Size of Sibling #3

Youth
Adult

T-Shirt Size Sibling #3

Legal Full Name of Sibling #4

First

Last

Age at time of application of sibling #4

Date of Birth of Sibling #4

Sex of Sibling #4

Male
Female

T-Shirt Size of Sibling #4

Youth
Adult

T-Shirt Size Sibling #4

Checkboxes

First Choice
Second Choice
Third Choice

Contact

7212 North Shadeland Avenue, Suite 100
Indianapolis, IN 46250
Phone: 317-913-WISH (9474)

Indiana Wish is a registered
501 (c)(3) Not For Profit Organization

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Check out our non-profit profile on GuideStar to see the great work we do for our community. We want to make sure you have the professional updates you need to confidently support our work with trust and confidence.

We're rated by Charity Navigator! You can give with confidence knowing that we have been independently evaluated for effectively stewarding donations. Charity Navigator - Rating for Indiana Wish, LLC

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Refer a Child
- Family or Friend
- Medical Professional
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Wish Family Corner
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