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Referral Inquiry Form

This inquiry form is the first step to receiving a wish – it is not confirmation of eligibility for a wish. Your information will be forwarded and you will be contacted by a member of our wish-granting team.

Relationship to child

Your information

We value your privacy and will not share your personal information.

Optional

Please confirm your email address. We want to make sure we can respond to your request.

Optional

Message

Type the characters below



Important Note

In the comments/question section of this form, please indicate your child’s life-threatening medical condition/diagnosis

Something to Consider

Please keep in mind that Make-A-Wish® does not cold call families of potentially eligible children. We ask you to please exercise compassion and suggest to families that they contact Make-A-Wish directly.

A second-party introduction can be unsettling for a child or the family. We prefer that the referral process be as comfortable, inspiring and private as possible.

Thank you for your consideration in this regard.

Please feel free to call us at 312.602.9474 (800.978.9474, toll-free) with any questions you may have.

Sí, hablamos español

Formulario de Recomendación en Español. Imprimir y fax al 312.602.9499 o por correo electrónico. Llame 312.602.9446 con preguntas.

Descargar el formulario (PDF)

Make-A-Wish® Illinois
640 North LaSalle Drive
Suite 280
Chicago, IL 60654
(312) 602-9474
Toll Free (800) 978-9474