Refer a Child

Dreams provide hope and inspiration to children and their immediate families during the most difficult times of an illness. The Dream Factory of St Louis is always looking for children in the St Louis metro area who are in need of help in living out their wildest dreams. If you wish to refer a child who lives outside our region, you can find a list of all Dream Factory chapters and their contact information at the Dream Factory National Headquarters website.

Anyone can nominate a child for a dream (parents, family friends, physicians and nurses, teachers) and the process is simple. If you know a qualifying child in the St Louis metro area that needs some joy, contact us to get the referral process started.

Download the Dream Factory of St Louis Child Referral Form here. (PDF)

Mail it to: THE DREAM FACTORY OF ST LOUIS ~ P.O. BOX 510715 ST LOUIS, MO. 63151 or fax it to: (314)846-1508


Child Referral On Line Form (best viewed while in fullscreen)

Child's Information (ALL FIELDS ARE REQUIRED)

 

Name:

Birthdate:

Social Security Number (required):

Email Address (required):

Address:

City:

State:

Zip Code:

Mother's Name:

Father's Name:

Home Phone: (with area code)

Mother's' Cell Phone: (if different) (with area code)

Father's' Cell Phone: (if different) (with area code)

Other Children (under 18 years of age) Living Full Time In The Same Household

Information About The Illness (ALL FIELDS ARE REQUIRED)

Name of Illness:

Name of Treating Physician:

Physician's Phone Number: (with area code)

Physician's Fax Number: (with area code)

Physician's Address:

City:

State:

Zip Code:

Referral Made By (ALL FIELDS ARE REQUIRED)

Name:

Phone Number: (with area code) (required)

Relationship To Child:

* The person submitting this referral must notify the family that they are being submitted before we can continue with the referral process.

Has The Family Been Notified: (yes or no)

Your Message To Us

Is There Anything Else We Should Know?