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Referral Form
This form must be completed in its entirety.

If you prefer, you may download the Referral Form (pdf), print and mail the completed form to:

Make-A-Wish Foundation of Hawaii
745 Fort St., Suite 315
Honolulu, HI 96813

Wish Child Information:

Name:  
 Sex: Male Female
Illness:  
 Primary Language(s) spoken:
Age:  
 
Birthdate:  
 
Current Address:
Address: 
City:  
    
State:  
    
Zip Code:  
    
     
Telephone:  
    
   
  Permanent Address (if different than current):
Address:  
 
City:  
    
State:  
    
Zip Code:  
    


Wish Information:
Is the child able to articulate his or her wish?
 Yes No
If no, how does the child communicate?
Does the child have developmental delays?
Yes No
Do both the parents have legal custody? Yes No
If no, copies of custodial paperwork will be requested at the time of interview.
Has the child received a previous wish by the Make-A-Wish Foudation® or another wish-granting organization? Yes No
Is this a RUSH wish? Yes No
If "yes", please specify time priority:
Is the child aware of the life-threatening nature of his or her condition? Yes No


Parent(s)/Guardian(s):

 		 
Name:  
  Mother: Father: Other:
Address: 
City:  
 Primary Languages Spoken:
State:  
Zip Code:  
    
Telephone:  
 (home)
Telephone:  
 (work)

Name:  
  Mother: Father: Other:
Address: 
City:  
 Primary Languages Spoken:
State:  
Zip Code:  
    
Telephone:  
 (home)
Telephone:  
 (work)
       
Siblings/Ages:


Physicial and Medical Information:
Physician Name:   
Hospital/Treatment Facility:   
Address: 
City:  
  
State:  
  
Zip Code:  
    
Telephone:  
 (office)
Fax:  


Referring Person:
Name:  
Telephone:  
Fax:  

Relationship to child (mark one):
Child
Parent/Guardian
Physician
Social Worker

Other:  


How did you hear about the Make-A-Wish Foundation?

Comments:

 

 

Jesse

Wish Sponsors:


Four-year old Jesse was not even born when Michael Jordan was a professional basketball player. But, Jesse is amongst the youngest fans of this basketball legend. His wish to meet Michael Jordan came true when the family flew from Hilo to chilly Chicago for a special meeting. Jesse was very, very happy to finally meet his idol. And as if that was not enough, the family enjoyed a Bulls home game, spent a day at the Shedd Aquarium, dined at ESPN Zone and shopped on Michigan Avenue.


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