Refer A Child:

Anyone can refer a child they think may qualify-- simply e-mail us with basic information on the child and BEERDRINKERSINC.COM will immediately begin working on initial steps to fulfill the wish.

In order to qualify for a Wish, a child needs to be under the age of eighteen when the completed application arrives to our office, and must be diagnosed with a life threatening illness. Finally, the Wish must truly be the child’s Wish, allowing them to fully experience the once in a lifetime opportunity of their dreams.

This form makes it simple to refer a child. Simply fill out the information in the form below and submit it to us online and we will begin right away. By taking a few minutes to submit information to BeerDrinkersInc.Com, you will be taking the first step in helping to create a once in a lifetime experience for a very special child.

Complete the form below:

Child's Personal Information:

First Name
Last Name
Date of Birth
Sex Male Female

Mother's Information:

First Name
Last Name

Father's Information:

First Name
Last Name

Contact Information:

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
E-mail

Number of immediate family members living at home:


Diagnosis:


Hospital Information:

Hospital Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone

Doctor Information:

First Name
Last Name
Work Phone

Notes on illness:


Referred By:


Wish Description:


Your Relationship to Child:


Your Contact Information:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
E-mail

 

The below typed signature certifies that the facts contained in this form

are true and complete to the best of his/her knowledge and accurate.

Signature:



Copyright © 2007 [BeerDrinkersinc.com]. All rights reserved.
Revised: 07/25/07