Relationship to child* ---SelfParent/GuardianMedical ProfessionalFamily Member / Relative / FriendOther
Title*
Date of birth*
Surname*
Given name(s)*
Residential address*
Suburb*
State / Territory* ---Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaWestern Australia
Postcode*
Mobile*
Daytime telephone*
Email*
Gender* ---MaleFemaleOther
Has this child ever received a wish grant from any wish granting organisation?* ---YesNoNot sure
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
Relationship to the child* ---MotherFatherGrandparentGuardianOther
What is the families spoken language?*
Does the child have siblings?* ---YesNoUnknown
Please list the childs siblings and their ages
Does the parent/guardian consent to this application?* ---YesNoUnknown
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*
Tell us in your own words why you think the child your referring should be selected*
Provider number*
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?* ---YesNo
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?* ---YesNo
What is your estimate of the patient's life expectancy?* ---Less than 12 monthsMore than 12 months
Please provide any further information that may assist with the patient's application.*