Application

REFERRER INFORMATION

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*

CHILD'S INFORMATION

Title*

Date of birth*

Gender*
---MaleFemaleOther

Surname*

Given name(s)*

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

PARENT OR GUARDIAN 1

Relationship to the child*
---MotherFatherGrandparentGuardianOther

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*

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

PARENT OR GUARDIAN 2

Relationship to the child*
---MotherFatherGrandparentGuardianOther

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*

Does the parent/guardian consent to this application?*
---YesNoUnknown

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?*
---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

If so, please set out all restrictions:

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.*