Nominate a Child Form » Magical Moments Foundation

Is family/child aware of the following nomination?

Yes No

Has the child been nominated within the last year?

Yes No

Do you grant permission to Magical Moments Foundation to use the nominated child’s photograph for fundraising material related to the requested magical moment?

Yes No

Nominator's Information

First Name*

Please enter a valid first name.

Last Name*

Please enter a valid last name.

Address*

Please enter a valid address.

Address 2

Phone Number*

Please enter a valid phone number.

Email*

Please enter a valid email.

Relationship to Nominated Child*

How did you hear about Magical Moments?*

Child's Information

First Name*

Please enter a valid first name.

Last Name*

Please enter a valid last name.

Date of Birth*

Please enter a valid date of birth.

Diagnosis*

Please enter a diagnosis.

Medical Providers Name*

Please enter a Name.

Medical Providers Phone*

Please enter a Name.

Medical Providers Email

Please enter a valid email.

Medical Providers Address*

Please enter a valid address.

Medical Providers City*

Please enter a valid email.

Medical Providers State*

Please enter a valid State.

Medical Providers Zip*

Please enter a valid zip.

Parent/Guardian Information

First Name*

Please enter a valid first name.

Last Name*

Please enter a valid last name.

Address*

Please enter a valid address.

Address 2

City*

Please enter a valid city.

State*

Please enter a valid state.

Zip*

Please enter a valid zip.

Phone Number*

Please enter a valid phone number.

Email Address*

Please enter a valid email.

Tell Us More

Tell us this child’s special story:

Describe in detail this child’s wished-for Magical Moment:

Discuss the impact that the Magical Moment will have on the child?

Recent Photo of Child Being Nominated

Nomination Form