Workers 4 Wishes Apply For A Wish

Name*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Relation to the Child*

If you are not the child’s parent / guardian, please include the primary parent’s contact information: *

Is the parent aware that this referral is being made? *

Child’s Name

Child’s Age ( Include Date of Birth, if possible)

City / Town of Residence

Type a question

Please tell us a little about the child’s current (medical) condition & history. We do not need excessive information, however we do require enough information to make an informed decision on whether his/her condition is life-threatening. If it is helpful to you, you may attach a letter or statement from a health care professional who knows the child. You may also include a photo or other information to personalize the application. Please share what you are comfortable sharing with our committee.

Wish Ideas - We ask each child/family to consider at least two tentative wish ideas. After acceptance, we work closely with the family, to tailor the wish to the child’s individual needs. If you have thoughts on what kind of wish s/he would like and you’d like to share, we’d love to hear it. This helps us get to know the child a bit more, and his/her likes and needs. Please include any particular strengths or challenges (such as sensory or mobility challenges) that may need to be considered in us customizing a wish for this child.

How did you learn about Workers4Wishes?

Please note, a submission of application will not necessarily result in a wish being granted. If you have a question about the receipt of or status of an application, please email us at info@workers4wishes.com .