Please fill in all the required values with *

About the child

You have reached the character limit
You have reached the character limit
The child must be between the ages of 3 and 17
You have reached the character limit
You have reached the character limit

Please note: If the child has received a wish from another organisation, we'll be unable to grant them a wish.

You have reached the character limit

About the family

You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit

About you

You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit

About the child's consultant/doctor

Please provide details of the child's medical consultant. Please note: this shouldn't be details of the child's GP.

You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit
You have reached the character limit