Do you know a child who may be eligible to receive a dream? If so, please fill out the information below and it will be sent to our staff. We'd like to make more dreams come true!

Child Information
Name:
Date of birth:
Age:
Illness:
Parent's name:
Street address
Address (cont.)
City
State
Zip
Phone:
Physicians name:
Referring Person
Name:
Relationship to Child:
Phone:
E-Mail:
Is the children's family aware of the referral?
	Yes    No
Additional information:
How did you hear of the Dream Factory?
To ensure web security, please type the word "DREAM" into the textbox immediately to the right:

Dream request applications are available from our office for children who meet the following criteria:

• The child must be between the ages of 3 and 18
• The child must have a serious or chronic illness as determined by his or her physician and our screening committee
• The child cannot have received a dream, wish or gift from any other wish-granting organization
• The dream must be the child's, not that of his or her parents or another concerned party