Wish Candidate Name: * | |
Wish Candidate Address:
(MUST BE LOCATED IN SOUTHEAST WISCONSIN TO BE CONSIDERED) |
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Wish Candidate Phone: | |
Wish Candidate E-mail: | |
Where did you hear about Eternal Wish? (please be specific) * | |
Wish Request: * | |
Significance of the wish request? (tell us the story or why wish candidate is deserving): * | |
Is Wish Applicant Medicaid Eligible: * | |
Is wish applicant at least 18 years old? * | |
Does wish applicant have a physician documented terminal diagnosis? * | |
Is wish applicant located in Southeastern Wisconsin? (CURRENTLY WE ARE ONLY ACCEPTING WISH APPLICATIONS FROM WISH APPLICANTS LOCATED IN SOUTHEASTERN WISCONSIN!!!) * | |
Nominating Party Name: * | |
Nominating Party Address: |
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Relationship to Candidate: * | |
Nominating Party Phone: | |
Nominating Party E-mail: | |