Wish Referral Form

If you know a child who you feel may qualify for a wish, please submit this form.

Important! This form cannot be submitted unless all boxes marked with an * have been completed.

Child Information

Child's Name*:

Child's Age*:

Gender:

BoyGirl

Please provide a diagnosis and/or a brief description of the child's illness*.

Family Information

Parent/Legal Guardian's Name*:

City*:

Phone*:

Email:

Primary Language*:

Referrer's Information

Your Name*:

Your Phone*:

Your Email*:

Your Relationship to Child*:

Referral Verification

The Rainbow Society of Alberta does not solicit wishes as the family may not be ready to accept a wish as part of their lives at this time. Therefore, please respond to the following statement:

The parent or guardian named about is aware that you are referring their child*.
YesNo