Wish I Could Of NorthEast Louisiana, Inc.
P.O.Box 7903 Monroe, La. 71211
Phone: (318) 728-2300
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 this completed form and the doctors diagnosis and prognosis to the address listed above.
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