Referral Form

Please fill out the form below to refer a child for a Wish. Please note that all referrals will be treated in the strictest confidence.

Fields marked with * are mandatory

Child's Full Name:
 *
Child's Date of Birth/Age:
 *
Child's Illness:
 *
Hospital Attended:
Parent/Guardian Names:
 *
Family Address:
 *
Family Home Phone:
 *
Family Mobile Phone:
Other Info:
 
Referrer's Name:
 *
Relationship to Child:
 *
Referrer's Telephone:
 *
Referrer's Mobile Phone:
Referrer's Email Address:
How You Heard About Us:
 
To the best of your knowledge:
Has The Child Previously Received A Wish?
Is The Child Registered With Another Wish Granting Charity?
We like to keep in touch with our referrers and send information on developments within Round Table Children's Wish. If you do not wish to be contacted in future please tick the box.
NOTE: At no time will we pass your information to other organisations.
 

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