Magic Moments Digital Application

Step 1 of 3

Child's Name(Required)
Child's Sex(Required)
MM slash DD slash YYYY
Home Address(Required)
Who Has Custody?(Required)
Does legal guardian have valid driver's license?
Is the child a U.S. Citizen?(Required)
Physician's Address(Required)
Child's Social Worker (If Applicable)
Is your child cognizant he/she is receiving/making a magic moment?(Required)
Has he/she missed school due to the illness?(Required)
Does your child use a wheelchair as his/her primary means of mobility?(Required)
Are any of your other children eligible for a magic moment?(Required)
MAGIC MOMENT REQUEST: (List top 3 - only one will be granted) Travel is limited to Continental United States only.(Required)
If magic moment involves travel, it will include only 2 adults and siblings 18 and under living in the home.(Required)
Please include first and last names, DOB, and relation to child