Express Wish Nomination

"Express" Wish Nomination

Sometimes the biggest things in life are also some of the smallest. An "express" wish is a special program to facilitate wish requests with greater speed and much less paperwork than a traditional wish request. It is for those experiences in life that are low in monetary value (under $100) but high in sentimental value. Examples include, but are definitely not limited to, a deck of cards, a journal to write down memories, a dinner for two people, or various other items/experiences that our close to an individual's heart. (All nominations must be filled out by a social worker or medical professional with direct knowledge of nominee's condition.)

1. "Express" Wish Qualifications - All Answers must be "yes" to qualify
Does nominee have a life threatening condition (with a likely life expectancy of less than one year)?*

YesNo
Is the wish request for an experience that has a fair market value less than $100?*

YesNo
Does the nominee have a hardship that prevents self-fulfillment of the wish request?*

YesNo
Is the wish nominee located in Southeastern Wisconsin or South Dakota?*

YesNo
What is the wish request for? (Be Specific)*
Explain why your nominee deserves the selected award.

3. Your Information
Are you a related party to the nominee?*

YesNo
Are you a social worker or medical professional that attests to the validity of the nominee's condition?*

YesNo
Your Name*

First NameLast Name
Company or Healthcare Facility*
Your E-mail Address*
Your Phone Number*

Area CodePhone Number
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Should be Empty:

"Express" Wish Nomination