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If you’re part of a family with a child with a life threatening illness, or know a family with a child with a life threatening illness and would like the opportunity of an international holiday or a local getaway, please apply with the online form here or download the form below.

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REFERRER INFORMATION

Relationship to child* Title* Date of birth* Surname* Given name(s)* Residential address* Suburb* State / Territory* Postcode* Mobile* Daytime telephone* Email*

CHILD'S INFORMATION

Title* Date of birth* Gender* Surname* Given name(s)* Has this child ever received a wish grant from any wish granting organisation?* Specify which organisation, and date of wish* In order to facilitate communication, please tick all the boxes that apply to the child that you are currently referring*
This child is non-verbalThis child is developmentally on target for chronological ageThis child functions at a 0-2 year old, sensorimotor stageThis child functions at a 2-7 year old, preoperational stageThis child functions at a 7-11 year old, concrete operational stageThis child functions at an 11+ year old, formal operational stageSorry, I am not to sure

PARENT OR GUARDIAN 1

Relationship to the child* Title* Date of birth* Surname* Given name(s)* Residential address* Suburb* State / Territory* Postcode* Mobile* Daytime telephone* Email* What is the families spoken language?* Does the child have siblings?* Please list the childs siblings and their ages Does the parent/guardian consent to this application?*

PARENT OR GUARDIAN 2

Relationship to the child* Title* Date of birth* Surname* Given name(s)* Residential address* Suburb* State / Territory* Postcode* Mobile* Daytime telephone* Email* Does the parent/guardian consent to this application?*

CHILD'S MEDICAL INFORMATION

What is the nature of the child's medical condition (including diagnosis, prognosis and current treatment needs)?* When was the child diagnosed with this condition?* Please specify Treating doctors consulted for the child's medical condition*

TESTIMONIAL

Tell us in your own words why you think the child your referring should be selected*

SPECIALIST MEDICAL REPORT

Title* Provider number* Daytime telephone* Surname* Given name(s)* Patient's title* Patient's date of birth* Patient's surname* Patient's given name(s)* Provide full details of the patient's diagnosis and prognosis* When was the medical condition first diagnosed?* When did the patient last consult you for this condition? When is the next consultation scheduled?* What treatment is planned for the future?* Are there any physical restrictions on the patient's ability to travel travel overseas or participate in any local experience?* If so, please set out all restrictions: Are there any medical or treatment restrictions on the patient's ability to travel overseas or participate in any local experience?* If so, please set out all restrictions: What is your estimate of the patient's life expectancy?* Please provide any further information that may assist with the patient's application.*