1 Details
2 Guardian
3 Medical
4 Consent

    Child’s Details

    First name

    Middle name

    Surname

    Known as

    DOB

    Age

    Gender

    Residential address

    Suburb

    City

    Postcode

    NHI No

    Cultural Considerations

    Knowing as much as we can about your family helps us to deliver the best possible wishexperience for your child. To ensure that Make-A-Wish New Zealand is aware of any culturalsensitivities, please indicate the cultural group your child identifies with.


    Is English the first language

    Are you a NZ Resident?

    Additional Criteria
    To ensure that as many kiwi children as possible receive a wish, kindly select this checkboxto confirm that the applicant has not already received a wish from any other wish grantingorganisation. The applicant agrees to inform Make-A-Wish New Zealand and acknowledge thatthey may no longer be eligible for a wish from Make-A-Wish New Zealand if they receive one inthe future.

    Wish Request

    Your child does not need to know their wish at this stage, however if they have an idea, pleasebriefly describe below:

    How Did You Hear About Make-A-Wish New Zealand?

    Legal Guardian Details

    Child resides with

    Guardian 1

    Relationship to child

    First name

    Surname

    Address (if different from child)

    Suburb

    City

    Post Code

    Home No

    Work No

    Mobile Number

    Email

    Guardian 2

    Relationship to child

    First name

    Surname

    Address (if different from child)

    Suburb

    City

    Post Code

    Home No

    Work No

    Mobile Number

    Email

    Sibling Details

    Full name

    Gender

    DOB

    Resides with child ?

    Full name

    Gender

    DOB

    Resides with child ?

    Full name

    Gender

    DOB

    Resides with child ?

    Full name

    Gender

    DOB

    Resides with child ?

    Details of Other People in the Household

    Full name

    Relationship to the child

    Age

    Gender

    Full name

    Relationship to the child

    Age

    Gender

    Medical Information

    Child’s illness and current health status

    Can your child communicate verbally?

    Is the wish medically urgent ?

    Is your child mobile ?

    Medical Information

    First name

    Surname

    Hospital and Department where specialist treats your child.

    Make-A-Wish New Zealand will contact this medical specialist to determine your child’s eligibility

    Hospital

    Department

    City

    Phone number

    Email

    Applying as

    First name

    Surname

    Organisation / Hospital

    City

    Phone number

    Email

    Consent

    By signing the wish request form, you authorise Make-A-Wish NewZealand to collect, maintain, use and disclose the personal informationin the manner set out in the Privacy Statement.

    This section must be signed in order for the wish request to beprocessed.

    Looking after your Privacy

    Your right to privacy is important to us. This statement explains yourprivacy rights and our obligation and rights in relation to collection anduse of your personal information.

    * Please refer to our privacy policy

    Please sign

    Make-A-Wish® New Zealand is an affiliate of Make-A-Wish® - the world's largest wish-granting charity. Funds donated to Make-A-Wish New Zealand go towards helping grant wishes for children in New Zealand.

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