|
Date ___________________ |
|
Dream Request Form |
| Please complete form and return to: |
| ATTN: Tracy Dirst |
| The Central Illinois Dream Factory, Inc |
| Post Office Box 1431 |
| Pekin, IL 61554 |
| Child's Name __________________________ Child's Birthdate ________________ |
| Parent or Guardian's Name ________________________________________________ |
| Complete Address ______________________________________________________ |
| County ____________________________________ |
| Home Phone #'s: Mother _________________ Father _______________________ |
| Names and Ages of Brothers and Sisters (18 yrs and under) |
| ____________________ _______________________ _____________________ |
| Child's Dream ___________________________________________________________ |
| Child's Medical Condition: _________________________________________________ |
| Physician's Name(s) ______________________________________________________ |
| Physician's Address ______________________________________________________ |
| Physicians Phone # _____________________ |
| Name of person making request __________________ Referrers Phone #____________ |
| Relationship to child ______________________________________________________ |
| Has the child previously received a dream from any wish-granting organization? _________ |