Refer a Child

Although we receive most of our referrals from parents/guardians and members of the medical community, we also rely on you - residents of Alabama communities who know a child in need of a magic moment. All information we receive concerning the child is kept confidential.

If you would like to refer a child, please fill out the form below. If the child meets our criteria, we will contact the family and begin the application process.

If you prefer to speak with someone directly, contact our Statewide Magic Moment Coordinator, Shequita Malone at 205.638.9608 or email shequita.malone@childrensal.org

Child's Name:
Child's Age:
Diagnosis:
Had a wish before?:
Yes No
Address:
Parent's Name:
Your Name:
Your Phone:
Your Email:
Relationship to Child:
Parent's Phone Number