Refer A Child for a
rainbow Connection Wish

Child's Full Name(Required)

Child's Birthdate(Required)

Child's Gender(Required)

Parent(s) or Guardian(s)(Required)

Phone Number (with area code)(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Has the child ever received a wish from any other organization or are you currently working with any other organizations? *(Required)

Child's Physician (If known)

Physician phone number (with area code)

Physician fax number (with area code)

Child's Illness(Required)

Hospital Child Is Being Treated At (if applicable)

Family's Social Worker (if applicable)

Relationship(Required)

Your Name(Required)

Your Phone Number (with area code)(Required)

Your Email(Required)

Please let us know if there is anything else you would like to tell us.

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