about us
history
faqs
board members
staff members
corporate sponsors
news & media
wish video library
granting wishes
refer a child
meet our wish kids
testimonials
embracing families
resources for wish families
ways you can help
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volunteer
host/sponsor an event
financial contributions
upcoming events
22nd annual polar plunge
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our new book I out now
Resilient Hearts: Navigating Your Child's Life Threatening Illness with Love and Hope
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child referral form
wish child
Child's Name
Date of Birth
Gender Identity
Medical Condition
Is the child able to communicate?
Yes
No
Primary Language Spoken
Does the child have any developmental delays?
Yes
No
Has the child’s medical condition involved ongoing medical interventions/treatment/procedure?
Yes
No
Has the child needed long term and/or recurrent hospitalizations?
Yes
No
Has the child ever received a wish from any other organization(s)?
Yes
No
Does the child reside with both biological parents?
Yes
No
siblings
Please list the names of siblings living with the wish child:
parents
Mother's Name
Email
Address
Home Phone
Mobile Phone
Father's Name
Email
Address
Home Phone
Mobile Phone
physician information
Physician's Name
Practice
Hospital
Phone Number
Fax
Address
person referring child
Name
Relation to Child
Is the family aware of the referral?
Yes
No
Phone Number
Fax
How did you hear about us?
Date of Referral
child's story
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
ways you can help
donate
Your contribution helps make dreams come true. Every dollar counts toward enriching lives.
volunteer
Join our team and make a direct impact! Your time and skills can change lives.
sponsor an event
Partner with us to create memorable experiences. Showcase your brand while supporting a worthy cause.
financial contributions
Your financial contribution brings joy and relief to our Wish Kids and Wish Families.
donate
401-781-9199
6 jefferson drive,
coventry, ri 02816
awish@awishcometrue.org
05-0398808
history
faqs
board members
staff members
corporate sponsors
news & media
wish video library
impact reports
financial reports
refer a child
meet our wish kids
testimonials
resources for wish families
donate
volunteer
host/sponsor an event
financial contributions
donate
donate