Refer a Journey Nominee
Please fill out the form as accurately as possible. Providing detailed information will be helpful in our review process. Submission of this form does not guarantee selection for a trip. A team member will review your referral and follow up with you.
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Individual
*
Nominee Information
Nominee Name
*
First Name
Last Name
Nominee's Email
*
example@example.com
Nominee's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age of Nominee (must be 21+)
*
Nominee's Hometown/State
*
What is the nominee’s diagnosed rare genetic disorder?
*
What inspired you to nominate this individual?
*
Has this individual been granted a Make-A-Wish? If so, when?
*
Please add any additional information you feel we may need to know about this individual for our selection process.
Submit
Should be Empty: