Initial Wish Application

Wish Candidate Name: *
Wish Candidate Address: (MUST BE LOCATED IN SOUTHEAST WISCONSIN TO BE CONSIDERED)
Wish Candidate Phone:
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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:
Relationship to Candidate: *
Nominating Party Phone:
-
Nominating Party E-mail: