Initial Wish Application

Wish Nomination

All nominations must be filled out by a social worker or medical professional with direct knowledge of nominee's condition.
- Does the nominee have a life threatening condition (with a likely life expectancy of less than one year)?*
  
  YesNo
- Does the nominee have a financial 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.
- Nominee's Name*
  
  First NameLast Name
- Nominee's Phone Number (optional)
  
  Area CodePhone Number
- Nominee's E-mail Address (optional)
- Nominee's Address (optional)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- 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:

Wish Nomination