Individual Visit Request Form
We rely on referrals from caring individuals to help us reach more kids with critical illnesses every year and provide them with an experience. The eligibility consideration process is initiated when a wish referral inquiry is submitted and fulfilled by a local chapter.

WHO CAN REFER A CHILD?
Children being treated for a critical illness
Parents or legal guardians
Medical professionals (typically a doctor, nurse, social worker or child-life specialist)
Family members with detailed knowledge of the child's medical condition

WHO IS ELIGIBLE?
Typically, A Moment of Magic provides our services to children with critical illnesses who has reached the age of 2½ and is younger than 18 at the time of referral, however we do extend these boundaries depending on specific circumstances.
Email address *
RELATIONSHIP TO CHILD *
HOW DID YOU HEAR ABOUT A MOMENT OF MAGIC? *
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