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Suggest A Child

Thank you for your interest in Special Wish Child of East Texas.

If you know of a child in our community between the ages of 5 and 18, who is terminally ill or permanently disabled, please fill out and submit the form below.

All information is private and will not be shared with any third parties.


Fields marked with an * are required.

Child's Information:

Name:
Address:
City:
State:
Zip Code:
Birth Date:
Age:

School:

Grade:
Disability/Illness:
Primary Doctor:
Primary Doctor's Phone:

Child's Parent or Guardian:
Parent or Guardian's Relationship to Child:
Is the Child's Parent or Guardian aware of this recommendation? (Please explain)
Additional information you feel might be helpful:
Your Information:
Name:
Address:
City:
State:
Zip Code:
Phone (Days):
Phone (Evenings):

*Email Address:
Relationship to Child:

Questions or Comments:

 
   
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