Beyond the Moon

Wish referral

Wish Referral FORM

If you know a child that may qualify for a BEYOND THE MOON wish, please print the form below, fill it in and send it back to us either by fax at +32 15 23 36 82 or by post at the following address: BEYOND THE MOON, Zandstraat 27k, 2223 Schriek, Belgium. Thank you.

BEYOND THE MOON handles every application following a well considered list of criteria

BEYOND THE MOON fulfils wishes for families across Europe. If you wish to refer a child and/or support our organisation from outside Europe (except for the US), it is always possible. Should it be the case, we kindly ask you to contact us.

Date of referral:
First name*:
Last name*:
Your relation to the child you wish to refer: Parent Medical professional Self (sick child) Other

Your e-mail address:
Your telephone number:
Child's full name:
Child's gender:	Male Female
Child's date of birth*:
Child's illness:
Name parent(s)/guardian:
Country of residence of child:
Telephone number parent(s)/guardian:
Child's primary care physician's name:
Primary care physician's hospital:
Primary care physician's telephone number:

To avoid disappointments, no promises should be made to the child towards the outcome of the application. BEYOND THE MOON respects the privacy of the children and families it serves. All medical information is considered confidential and is not discussed with third parties unless it is required for the wish and the child's parent(s) or guardian(s) have given their consent.