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Fill-A-Wish Application

The VIAD Charity Fund has set up a fund to grant that special “wish” to a special needs child 18 years old or younger. If you have a family member or know anyone in your area that would qualify for this benefit, please complete the application below.

Contact information: VIAD Charity Fund, ATTN: Fill-A-Wish, 1525 Huguenot Road, Suite 102, Midlothian, VA 23113. Phone: (800) 394-1960. Fax: (757) 299-6331. Email: info@viada.org.

Child Information

Name of child

Age

Sex

Child's address

Phone

Parent / Guardian Information

Mother's name

Mother's occupation

Mother's address

Mother's phone

Father's name

Father's occupation

Father's address

Father's phone

Medical Information

Nature of illness

Date of diagnosis

Attending physician

Physician address

Physician phone

Physician prognosis

Hospitalized?

Name of hospital

Address of hospital

Special Wish

Child's special wish

What is VIADA?

Virginia Independent Automobile Dealers Association is a professional association that promotes integrity, honor, and fair dealings toward the public as well as compliance with all regulations governing the auto sales business. Its members make the Charity Fund's charitable acts possible through their generous donations. Many thanks are due to these wonderful automobile dealers.