CWFI VISA
Apply and Make a  
 difference with every  
 purchase!
Child's First Name: Child's Last Name:
Child's DOB:
Gender: Male Female
       
Mother's First Name: Mother's Last Name:
Father's First Name: Father's Last Name:
Street Address:
City:
State:
Zip or Postal Code:
Country:
Home Phone: -  -
Parent's Email:
 
 
If you need an application sent to an address that is different from your home address, please provide the information below.
First Name: Last Name:
 
If staying at a residence such as Ronald McDonald House please include the following information:
Street Address:
City:
State:
Zip or Postal Code:
Country:
Number of immediate family members living at home:
Diagnosis:  *Required
Hospital Name:      
Hospital Street Address:
Hospital City:
Hospital State:
Hospital Zip or Postal:
Hospital Country:
Hospital Phone: - -
 
Name of Doctor treating child for this illness:
Doctor's Phone: - -
 
Notes on Illness:
Wish Description:
Referred By:
Your Relationship to Child:
Your Street Address:
Your City:
Your State:
Your Zip or Postal Code:
Your Country:
Your Home Phone: - -
  The below typed signature certifies that the facts contained in this form are true and complete to the best of his/her knowledge and accurate.
Signature:   *Required
   
   
 

 
              Children's Wish Foundation International, Inc.  8615 Roswell Rd.  Atlanta, GA 30350   1-800-323-WISH