Wish Referral - Make-A-Wish

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Email address. Where did you hear about Make-A-Wish? Medical release form. Signed. Wish Referral. 22970_ReferAChild Leaf
About the child Child’s full name

Child’s full name About the childFemale Male/Female Wish Referral Qualifying illness Male/Female Child’s full name Male/Female

Child’s date of birth 31 Child’s date of birth

Child’s date of birth Qualifying illness Primary language spoken Qualifying illness Male/Female Child’s date of birth Primary language spoken About the child Has the child received or registered for a wish from another organisation? Yes Primary language spoken Qualifying illness Has thefull child received or registered for a wish from another organisation? Yes Child’s name If Yes, which organisation? Has thewhich child received or registered for a wish from another organisation? Primary language spoken If Yes, organisation? Male/Female Child’s date of Yes birth If Yes, which organisation? Has the child received or registered for a wish from another organisation? Yes Qualifying illness

About the organisation? family If Yes, which About the family Primary language spoken Parent/guardian name About the family Parent/guardian nameor registered for a wish from another organisation? Has the child received

Home address Parent/guardian name About the organisation? family Home address If Yes, which Postcode Home address name Parent/guardian Postcode Mobile number: Mother Postcode Home address Mobile number: Mother About the family Email address Mobile number: Mother Postcode Email address Parent/guardian name Email address Mobile number: Mother Home address

No No

Don’t know Don’t know

No

Don’t know

No

Don’t know

No

Don’t know

1990

Home telephone number Home telephone number Father Home telephone number Father Father Home telephone number Father Home telephone number Father

Telephone number Telephone number Email address Telephone number Email address Email address Telephone number

Where you hear about Make-A-Wish? Mobile number Email address Your fulldid address (if different from above) Where you hear about Make-A-Wish? Aboutdid the child’s Consultant/Doctor (NOT your GP) Postcode Telephone number Name of Consultant/Doctor Mobile number Email address Name and hospital Where did address you hearofabout Make-A-Wish? Consultant/Doctor’s telephone number Consultant/Doctor’s fax number Email address

Medical release form Medical release form Please fill inrelease the section below, giving Make-A-Wish permission to receive medical information about this child. Medical form Medical release form

If the child is over 16, and they are able, they must sign this part themselves. I, parent/guardian, [insert your name]

Medical release form

hereby give permission for Consultant/Doctor [insert your Consultant/Doctor’s name below] to release the required medical information regarding [insert child’s name below] Signed Signed Signed Signed

Signed

Page 3

About the referrer Email address About the referrer Postcode Name About the referrer Name number: Mobile Mother Your relationship to the child Name About the referrer Your relationship to the child Email address Your full address (if above) relationship to different the child from Namefull Your address (if different from above) Postcode full address (if Your relationship to different the child from above) Postcode About the referrer Mobile number Postcode Your address (if different from above) Mobile Namefullnumber Where did you hear about Make-A-Wish? Mobile number Postcode Where did you hear about Your relationship to the childMake-A-Wish?

Yes

December

22970_ReferAChild 22970_ReferAChild 22970_ReferAChild 22970_ReferAChild 22970_ReferAChild Leaflet:03_MAWReferAChild Leaflet:03_MAWReferAChild Leaflet:03_MAWReferAChild Leaflet:03_MAWReferAChild Leaflet:03_MAWReferAChild 1/4/13 1/4/13 1/4/13 10:31 1/4/13 10:31 10:31 AMAM 10:31 1/4/13 Page AM Page AM Page 3 310:31 Page 3 AM 3

Wish Wish Referral Referral Wish Referral About the child About the child Wish Referral Child’s full name