"Making Memories" Event Wish Referral

This inquiry form is the first step to receiving a "Making Memories" Event Wish – it is not confirmation of eligibility for a wish. Your information will be forwarded and you will be contacted by a member of our wish-granting team.

Elgibility Requirements

Patients must be diagnosed with a life-threatening illness, be receiving active treatment, and be frequently hospitalized.
The child's primary physician and social worker should complete applications. When more than one diagnosis is involved, each attending physician must complete a medical statement.
Eligibility will be determined by the Foundation after physician's assessment.
Applications will be reviewed and approved by Program Director.

Steps for our Wish Recipents

Patients must live in DC, MD, or VA to be eligible for a wish
Gather all the information you will need for your wish application
Fill out your wish application.
Print and get child's verifcation form filled out by treating physician. Forms should be mailed to the following address (7124 Salem Fields Blvd. #123, Fredericksburg, Virginia 22407)
Receive approval for your event wish (Note: Only one Birthday Celebration Wish and one Milestone Celebration wish will be approved per month)
Sign your Wish Recipient Agreement and Return to us.
Meet your event Coordinator and Event Planner
Plan the perfect event for your little one
Enjoy your unique celebration

***Please note all applicants must be between the ages of 1 and 18 years of age. Due diligence will be made to plan an event within 35 miles of applicants home address as indicated on their application.***

Name *

First Name Last Name

Email *

example@example.com

Relationship To Child *

Self Parent/Guardian Medical Professional Family Member Other

How Did You Hear About Forever Moriah Foundation? *

Wish Child's Name *

First Name Last Name

Gender *

Male Female

D.O.B *

Date

Has the child ever received a wish from any other wish granting organization? *

Yes No

Child's Celebration Theme *

Parent/Guardian Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent/Guardian Email *

example@example.com

Parent/Guardian Phone Number *

Area Code Phone Number

Child's Primary Diagnosis *

Approximate Diagnosis Date *

Date

Is there a medical reason why we should move quickly? *

Yes No

Physician's Name *

First Name Last Name

Physician's Phone Number *

Area Code Phone Number

Physician's Email

example@example.com

Treatment Facility or Hospital *

We ask that you submit your application at least 8 weeks prior to your desired event date. Please allow 2 weeks for your application to be reviewed and a determination email to be sent.

For any questions or concerns please feel free to email us at info@forevermoriah.com

www.forevermoriahfoundation.org