Let's bring some smiles!

Refer a family

Who is Eligible?

A child with cancer who are below the age of 23, special considerations for those above would also be considered.

REFERRAL FORM

This inquiry form is the first step to receiving a getaway – it is not confirmation of eligibility for a getaway. Your information will be forwarded and you will be contacted by a member of our team.

Parent or Legal Guardian's Name*

Phone

Address

City

State

Postal Code

Child's Name

Child's Perferred Name

Child's Date of Birth

Gender

Primary Diagnosis

Approximate Diagnosis Date

Primary Hospital or Treatment Facility

Do you need this trip within the next 6 months?

Yes

Please list any medical or scheduling restrictions (e.g. doctor appointments, procedures, and surgeries).

Destination Dino Liam

Destination Dino Liam

Destination Dino Liam

Let's bring some smiles!

Refer a family

Who is Eligible?

REFERRAL FORM

ADDRESS:

PO BOX 628 Slinger WI 53086-0628

PHONE:

262-305-9161

Destination Dino Liam

Donate

Destination Dino Liam

Destination Dino Liam

Destination Dino Liam

Let's bring some smiles!

Refer a family

Who is Eligible?

REFERRAL FORM

ADDRESS:

PO BOX 628 Slinger WI 53086-0628​

PHONE:

262-305-9161

Destination Dino Liam

Donate

PO BOX 628 Slinger WI 53086-0628