Refer A Child

WISH KIDS

Referral Form for possible Wish Kids

Do you know a child between the ages of 3-21 who has a terminal or life-threatening condition in Spokane, the Tri-Cities or Northern Idaho? Refer them to the Wishing Star Foundation! Have questions about a referral form you submitted? Wish Program Managers: Spokane and Northern Idaho Avery: [email protected] Tri-Cities Ashleigh: [email protected].

"*" indicates required fields

Wish Kid Referral Form

Do you know a child between the ages of 3 and 21 years of age who might qualify as a Wishing Star Foundation Wish Kid? Please send us a referral so we can connect!

Child's Name*

Child's Age*

The child must be between 3 and 21 years old in order to qualify.

Child's Condition (If Known)*

Gender of Child*

Male

Female

Family's Primary Language*

Parent/Guardian Name*

Family's Phone Number*

Family's Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Name*

Your Email*

How do you (aka the referral person) knows the child or what is your connection to the child? **

Would you like to keep this referral anonymous?*

Yes

Have you contacted the family about making this referral to Wishing Star?*

Yes

Has the child received a wish from another wish granting organization?*

Yes

I am not sure

Comments:*

Please tell us more about this family's situation or any other information you think we should know.

This field is for validation purposes and should be left unchanged.

REFER A CHILD

Referral Form for possible Wish Kids

Wish Kid Referral Form

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