Referral - Mainely Wishes

Referral Form

Mainely Wishes - Referral application

Out of respect for the privacy of our potential wish recipients we serve, people who may be eligible to receive a wish can be referred by one of the four sources:

Medical professionals treating the child i.e., doctors, nurses, social workers, childlife specialists
A parent or legal guardian of the potential wish person
The potential wish person
Friends

To refer, fill out the fields below, or download the form here to fill out and send to mainelywishes@gmail.com.

After filling out form below, if you have more information or documents please email them to mainelywishes@gmail.com

*All fields are required.

Your Name:

Your Phone:

Your E-Mail:

Your Relationship to the person you wish to refer:

Has this person had a wish granted before by Maine-ly Wishes:

Yes

Has this person had a wish granted by any other organization?:

Yes

*If yes, which organization?:

Person's Name:

Person's Age:

Parson's City:

Reason for Referral (please attach any additional information):

Family Phone:

Family Email:

Where did you learn about the Maine-ly Wishes?:

Comments:

Please attached Docs here:

PDF or Word Documents can be up to 20MB in size.

SPAM Protection:
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Privacy Notice

Your registration information is for the use of Mainely Wishes only. We collect information in order to keep you informed of contests and events sponsored or promoted by Mainely Wishes. Mainely Wishes will not sell, rent or in any way distribute personal information supplied to us by you. The information you provide us stays with Mainely Wishes only.