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.