Wish Request Form

First Name *

Last Name *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Date of Birth *

Gender *

Male

Female

First Name *

Last Name *

Address same as wish child *

Yes

No

Address *

Apt, suite, etc.

Country

City

State

Zip code

Phone *

Cell Phone *

Email *

First Name *

Last Name *

Address same as wish child *

yes

no

Address *

Apt, suite, etc.

Country

City

State

Zip code

Phone *

Cell Phone *

Email *

Does the child reside with both biological parents? *

Yes

No

Who has legal custody? *

Both

Mother

Father

Guardian*

Guardian Other than Parents Instructions

*If Guardian or if different from parents listed above, provide name and address of conservator/guardian (and furnish letters of guardianship):

Guardian Address Same as child *

Yes

No

Guardian Address *

Apt, suite, etc.

Country

City

State

Zip code

Phone *

Email *

Physician Name *

Physician Phone *

Diagnosis of child\'s illness: *

How did you hear of Wishing Well Texoma? *

Have you ever applied for wish with Wishing Well Texoma or other wish agency? *

List all wishes, trips, gifts, etc. previously denied or granted (include dates and non-profit agencies): *