Refer a Child Online Form
Out of respect for the privacy of the children and families we serve, children who may be eligible to receive a wish can be referred by one of three sources:
  • medical professionals treating the child i.e., doctors, nurses, social workers, child-life specialists
  • a parent or guardian of the potential wish child
  • the potential wish child

If you are not eligible to refer a child, please ask the child's family to visit our web site, contact their local chapter or contact the national office at 1-888-822-9474.
Your Name:
Your relationship to the child you wish to refer:
Parent/GuardianMedical ProfessionalSelf (potential wish child)
Has this child had a wish granted before *: YesNo
Has this child had a wish granted by any other organization? *: YesNo
If yes, name of organization:
Address:
City/Province:
* Postal Code:
Phone:
* Email:
Child's Name:
Child's Age:
Child's Medical Condition:
Where did you learn about Make-A-Wish®:
Comment: