Refer a Mom This form is the first step to receiving a wish. It is not a guarantee of a wish. Your information will be reviewed and you will be contacted by a member of the Ally’s Wish Team. Please fill out this form completely. Your Name Your Email Relationship to candidate: SelfMedical ProfessionalFamily MemberClose Friend Mom's Information Has this mom been a recipient of a wish (from any organization) in the past? YesNo If yes, please explain. Mom's Name Mom's Address Mom's City Mom's State Mom's ZIP Mom's Phone Mom's Email Confirm Mom's Email Your Information (if different than mom) Referrer Address Referrer City Referrer State Referrer ZIP Referrer Phone About the Mom Tell us about the life and family of the mom being referred: Please tell us about the diagnosis and history of the mom’s illness*: Tell us in detail about the mom's Wish: *Documentation from a medical professional will be required if selected to receive a wish. Note: Wishes involving travel will be capped at a $5,000 and 5-night limit. Ally’s Wish does not grant monetary wishes. You can make a difference. Give to Ally's Wish today.