WISH BY SWIISH ENTRY FORM

WISH BY SWIISH ENTRY FORM

*By submitting this form, you agree to be subscribed to and receive communications from SWIISH
Name *

First Name Last Name
Email *
Contact Number *
So we can reach you easily. For land lines, please include the area code.
Address *

Street Address

Street Address Line 2

Town / Suburb State

Postcode Country
Link to your Facebook page (*optional)
Please enter full website page URL link to your account
Link to your Instagram page (*optional)
Please enter full website page URL link to your account
This WISH is for... *
Please Select
I am/they are suffering from... *
Name the illness or health condition
How long I have/they have been ill for... *
The length of time of the illness or health condition
Are you, or are they, currently undergoing treatment for this illness? Or has there been any treatment in the last 12 months? *

YES NO
WISH Recipient's Date Of Birth *

Day Month Year
Day-Month-Year
In 200 words or less – please tell us your/their health journey and what it would mean to be chosen to receive this WISH BY SWIISH™? *

Max. 200 words or less 0/200
TO COMPLETE YOUR ENTRY: Email us 5 supporting photos (if you're nominating someone else, please include at least one photo of the two of you together). In the same email, please also attach a short mobile phone video (max. 2 mins long) highlighting your/your loved one's health battle. Send to wish@SWIISH.com.au with subject line: YOUR FULL NAME – WISH BY SWIISH ENTRY *
Should be Empty: