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2023 Dalia's Wish Application

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Wish Trip Nomination

Nominate a child affected by mitochondrial disease for a trip of a lifetime!

Nominator's Name(Required)
Child's Name(Required)
Relationship to Child(Required)
Has the child ever been granted a wish from any organization?(Required)
Child's Date of Birth(Required)
Nominator's Address(Required)
Child's Address(Required)
Child's Parent or Guardian(Required)
Child's Primary Physician(Required)
Please provide an image of the nominated child.(Required)
Accepted file types: jpg, jpeg, png, gif.

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Pyruvate Dehydrogenase, Compassionate Use & Clinical Trials
Presented April 17, 2023

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