REQUEST AN APPLICATION

If you would like to request an application or refer a loved one for a wish, please send us the following information. Please review our WISH GRANTING GUIDELINES prior to completing the form. If your wish appears to qualify for our wish granting program, we will send you a Wish Packet via email or in the mail if you do not have email. If we have questions or concerns about your wish, we will attempt to contact you before sending the Wish Packet. If you don’t know what your wish will be, don’t worry. We’ll be happy to send you a Wish Packet anyway. Please complete this form as thoroughly as possible. We hope we will be able to make your ultimate wish come true.

	All fields are required
Name:
Relationship to WR*:
Street Address:
City, ST ZIP Code:
Home Phone:
Work Phone:
Mobile Phone:
E-Mail Address:
How did you learn about Fairygodmother Foundation:
Prospective Wish Recipient Information
Name:
Gender:	Male Female
Age:
Diagnosis:
Approximate Life Expectancy:
Has WR ever received a wish before, by FGM or another organization at any time?:
	Yes No
Is WR aware that an application is being requested on their behalf?:
	Yes No
Requested Wish:

* WR refers to Wish Recipient