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Be A Kid Again
Night Club
Home
About Us
Our Team
Past Projects
Donate
Refer a Child
Shop
Contact
Be A Kid Again
Night Club
Referrers please note
We are currently accepting referrals for services in 2025!
Child Referral
Family Information
*
Indicates required field
Child's Name
*
First
Last
Child's Gender Identity
*
Male
Female
Other
Prefer Not to Say
Child's Age
*
Parent / Guardian Name
*
First
Last
Parent / Guardian Phone Number
*
Parent / Guardian Email
*
Family's Place of Residence Address
*
Line 1
Line 2
City
State
Zip Code
Country
Is the family aware of the referral?
*
Yes
No
N/A
Primary Diagnosis / Reason for Referral?
*
Treating Medical Professional
*
First
Last
Treating Medical Professional Email
*
Treating Medical Professional Phone Number
*
Primary Hospital or Treatment Facility
*
Has this child ever received services from another wish-granting organization?
*
Yes
No
Not Sure
Referrer Information
Person Referring
*
First
Last
Relationship to Child
*
Referrer Phone Number
*
Referrer Email
*
Referrer Address
*
Line 1
Line 2
City
State
Zip Code
Country
Personal statement
Which of the following services are you requesting?
*
Christopher Kit
Virtual Design
In-Person Design
Please describe the child's medical and accessibility needs further including but not limited to medical equipment used daily, current activity level of child, any anticipated major surgeries or treatments in the next year.
*
Thank you!
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UA-175204774-1