Referral Inquiry Form

Wish Child Information

* Child's Name
0/50
Nickname
0/50
* Birthdate
0/50
* Age
0/50
* Home Phone
0/50
* Address (including City, State, and Zip Code)
0/250
* Medical Condition
0/250

Parent(s)/Legal Guardian(s) Information

* Parent/Legal Guardian
0/50
* Relation
0/250
* Address (including City, State, and Zip Code)
0/250
* Email Address
0/50
Work Phone
0/50
Home Phone
0/50
Cell Phone
0/50
* Primary Language
0/50
* Parent/Legal Guardian 2
0/50
* Relation
0/250
* Address (including City, State, and Zip Code)
0/250
* Email Address
0/50
Work Phone
0/50
Home Phone
0/50
Cell Phone
0/50
* Primary Language
0/50
* Does child reside with both biological parents? If no, additional information/paperwork will be required.
* If there are other children under the age of 18 in the family, living in the home, please list names and ages.
0/500

Physician and Medical Information

* Physician's Name
0/50
* Hospital/Treatment Facility
0/50
* Office Phone
0/50
Fax
0/50
* Mailing Address (including City, State, and Zip Code)
0/250

Referring Person

* Name
0/50
* Relation to child
0/50
* Phone
0/50
Fax
0/50
How did you hear about A Second Wish By Demetrius Inc.?
0/500
Is the family aware of the referral?

Second Wish Information

* Has the child received a wish from another wish granting organization?
If yes, what was the child's first wish?
0/250
Name of Wish Granting Organization
0/50
Phone
0/50
Month
0/50
Year
0/50
* Is the child able to verbalize his or her wish?
If no, how does the child communicate?
0/250
Does the child have developmental delays?
Is this a RUSH wish?
If yes, please specify time priority
0/250

Required Medical Documentation

1. Medical Information: The following information MUST be provided by a Qualified Medical Professional:


A Qualified Medical Professional must be a: Physician, Medical Practitioner or Registered Nurse

Nominee's Name and Date of Birth

Nominee's Diagnosis and Prognosis Only (No other medical information is needed)

Medical Information (MUST BE NO MORE THAN SIX MONTHS OLD)

If the Wish Request involves Long Distance Travel: A letter stating the Nominee is medically cleared for long distance travel. (Outside of the nominee’s home city)


2. A photo of the nominee, preferably by email. 

Required Medical Documentation

1. EMAIL: mail@asecondwish.org (Documents must be in a .PDF Format; Photo in a .JPG Format)

2. FAX: 1-800-626-0085

3. MAIL: A Second Wish By Demetrius Inc., - PO Box 25912, Tampa, FL 33622


*The required Medical Eligibility Form must be completed by the Qualified Medical Professional. That form and the nominee's photo and bio must be received within two weeks of the application submission in order for your wish request to be considered. If more time is needed, you must contact us to request and extension, otherwise your wish request file will be closed.