Refer A Child

Anyone can refer a child for consideration to A Special Wish Northeast Ohio.

Once the below form is filled out, please be patient with us to hear back from our Director of Wish Granting. Those who mark down an emergency wish on the form below will be contacted by a representative from our charity right away.

Once a wish child is qualified, the family will immediately be welcomed into our Sparkles of Joy and Food Drop programs and the Big Wish planning will begin!

Here are the qualifications to become A Special Wish Northeast Ohio family:

Must be a resident in Northeast Ohio
Child must have a life-threatening illness/disease
Child must be between birth and up to 20 years of age
Child has never had a ‘wish’ with any other wish granting organization

Referral Form

Child's Name

First Name

Last Name

Sex

Age of Child

Parent/Guardian's Name

First Name

Last Name

Parent/Guardian's Email Address

Parent/Guardian's Phone Number

(###)

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City of Residency

Child's Illness or Disease

Name of Hospital Where Child is Receiving Treatment

Who is the Child's Current Specialist for Their Illness or Disease?

Are There Any Siblings in the Household? Please List Their Names, Ages and Genders.

Does This Wish Need to be Fulfilled Within the Next 90-days or Less?

Has the Child Received a Wish in the Past?

Who is Referring This Wish Child? (What's Your Name?)

What is Your Relationship With the Wish Child?

Phone Number for Referral Contact

(###)

###

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Additional Comments

Refer A Child

Referral Form

Contact

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