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Dalia’s Wish Trip Nomination

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Wish Trip Nomination

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

"*" indicates required fields

Nominator's Name*
Child's Name*
Relationship to Child*
Has the child ever been granted a wish from any organization?*
Child's Date of Birth*
Nominator's Address*
Child's Address*
Child's Parent or Guardian*
Child's Primary Physician*
please put N/A if no equipment is needed
please put N/A if there are no travel restrictions
Please provide an image of the nominated child.*
Accepted file types: jpg, jpeg, png, gif.
This field is for validation purposes and should be left unchanged.

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Expert Series: Serial Casting and Toe Walking
Presented April 25, 2025

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Novi, MI 48376
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