Nominations | Grant a Wish Program

Child's Name*

First Last

Date of Birth*

Age*

Grade*

Program Interested In

Guardian's Name

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Guardian Phone*

Guardian Email

Nominator's Name & Organization*

First Last

Nominator Phone*

Nominator Email*

Child's Background

Check any and all that apply...

IF YOU WERE UNABLE TO SAY YES TO ANY OF THE ABOVE, THAT DOES NOT MEAN THAT YOUR CHILD DOES NOT QUALIFY.

We ask, with the help of your child (where appropriate), that you communicate your circumstances and why your child should be involved in this program. Document how your child's life will be bettered by participation and how he/she will better the community by participating. The more we can understand your situation, the better we are equipped to help.

Name

This field is for validation purposes and should be left unchanged.