Christopher Kids - Refer A Child - Christopher Kids - serving children through design.

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 *

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? *

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!

Submit

Referrers please note

Child Referral

Family Information

​Referrer Information

Personal statement

Thank you!

Referrer Information