Wish I Could Of NorthEast Louisiana, Inc.

P.O.Box 366
Rayville, La. 71269

Phone: (318) 728-2300
Fax: (318) 728-2304


Application


Child's Name: ___________________________________________________________________________

Child's Age: _____________________________________________________________________________

Child's Birthday: _________________________________________________________________________

Child's Illness: ___________________________________________________________________________

                        ___________________________________________________________________________


Child's Physician (Name): __________________________________________________________________

Child's Physician (Address): ________________________________________________________________


*** Please attach a signed statement from the child's doctor, on the doctor's letterhead,
giving the diagnosis and prognosis for your child.
We must have this information in order to make a determination about your child's wish***


Child's School:___________________________________________________________________________

Child's Grade: ___________________________________________________________________________

Parents/Legal Guardian: ___________________________________________________________________
(Address & Phone Number)
                  ______________________________________________________________________________

Have you ever been granted a wish by any other organization?      Yes__________ No__________

Best time to contact you:___________________________________________________________________





Mail or Fax this completed form and the doctors diagnosis and prognosis to the address listed above.