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Family Application General Intake Form

Today's Date*

Applicant Information

Parent/Guardian First Name*

Parent/Guardian Last Name*

Relationship to Recipient*

Phone*

Email*

Preferred Contact Method*

Phone Call

Text

Recipient Information

Recipient's Full Name*

Date of Birth*

Month

Day

Year

Gender*

Male

Female

Other

Prefer not to say

Please Explain

Diagnosis/Condition*

Approximate Date of Diagnosis

Physician Name and Contact

Family Information

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Siblings Name[s] and Age[s]*

Other Household Members*

Wish Information

Please describe the recipient’s wish or dream.*

Why is this wish meaningful to your recipient and family?*

Has your recipient ever received a wish from another organization?*

Yes

If yes, please provide details

Medical Consent

Physician's Statement: By signing below, I verify that the above-named recipient has been diagnosed with a life-threatening or severe medical condition. I support their participation in the Clemson Family Wish program.

Signature*

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Additional Information

How did you hear about Clemson Family Wish?

Is there anything else we should know about your family or your recipient’s needs?*

Parent/Guardian Consent

By signing below, I certify that the information provided is accurate and truthful. I consent to the Clemson Family Wish team contacting me and the recipient's physician for further verification and planning.

Signature*

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Date of Submission*

Month

Day

Year

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