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SUBMIT A WISH
To nominate someone for a wish to make their dreams come true fill out the form below.
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* Indicates required question
Name
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Your answer
Date:
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MM
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DD
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YYYY
Date of Birth:
MM
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DD
/
YYYY
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Home Phone
Your answer
Cell Phone
*
Your answer
Email
*
Your answer
Employer
Your answer
Occupation
Your answer
Marital Status:
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Single
Married
Divorced
Separated
Widowed
Living with someone
Other
Other:
Spouse Name
Your answer
Length of time together:
*
0-5 years
5-10 years
10+ years
Other:
Number of Child/Children
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Your answer
Name of Child/Children
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Your answer
Child/Children Date of Birth
*
Your answer
How many children live in the household?
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Your answer
Other pertinent family information:
Your answer
How long have you known the Nominee?
*
Your answer
Please check one of the following and list the requested Luewish:
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My nominee is in need. (examples include: spa day, groceries, gift card, gas card)
My nominee would like to provide help to others. (examples include: donating to shelters, providing books to children)
Other:
Please explain in detail your request.
*
Your answer
Why is this person a good choice for LueWish?
*
Your answer
Additional information you feel is important to consider:
Your answer
AS THE PERSON MAKING THE NOMINATION, PLEASE PROVIDE THE FOLLOWING:
FULL NAME:
*
Your answer
Gender:
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Male
Female
Other:
Address:
*
Your answer
City:
*
Your answer
State:
*
Your answer
Zip:
*
Your answer
Home Phone:
Your answer
Cell Phone:
*
Your answer
Email:
*
Your answer
Additional information:
Your answer
Enter your full name as your signature
*
Your answer
Today's Date
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MM
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DD
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YYYY
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