Magic Moments receives most of its referrals from two primary sources: parents/guardians or through members of the medical community. However, we sometimes receive referrals through members of the local community who are aware of a child who might be eligible for a magic moment.

All information concerning the wish recipient shall be kept confidential. If you would like to refer a child, please fill out the form below, and provide us with the necessary information so that we can contact the family and send them an application.

Or, if you prefer to speak with someone directly, please contact one of our wish coordinators at 205-939-9372, email us info@magicmoments.org, or fill out the form below. 

Please note we are not accepting applications for children with life-altering medical conditions at the present time.

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: