2014-11-03 11:49 · ~rabots4 12155901000 >" 

We f71Hlt the wisbe, of cbiidren with 

Jife·threatenin(f medical conditions tc 

eMich the hUJ11an experience with 

hope, strength and joy. 

B 

wos 

on S/16/2014 

by Or. Trude Haecker. 

This form is not intended to determine eligibility, but rather certifies that the child's selected wish 

is medically appropriate and identifies any medical restrictions and precautions that must be 

considered in granting this wish. 

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INSTRUCTIONS: This Wish Safety Authorization Form must be completed and signed by the referred child's physician who must be 

a licensed allopathic or osteopathic doctor of medicine, a certified nurse practitioner. or a certified physician assistant who has direct 

knowledge of the wish child's medical condition, and returned to the address below. This Wish Safety Authorization Form is being 

signed in connection with a wish that may be granted by Make-A·Wish for: 

Glqnn! McLqur!n hos wished to go to Q!1nev WJl1!d 1n Dl!cemb!!! 2014 

{Child's nome {"pollen!") (Child's wish) 

Parent{s)/legol guordion(s) {"parent"): Lynette Ward, Glenn Mclaurin 

Patient's dote of birth: 12121/2006 

Patient's physician ("physician"): Dr. Trude Haecker 

Physician's office phone #: (215) 590·1029 

Physician's address: CHOP 

Health Core Profcs.•iqnal: Plea.,;, indicate your dcterminati<m by checking the •cmronriats bn:<, 

WISH IS APPROPRIATE: leertiJy that conditions I through 3 hav• been met. 

I. I have <:l<plnincd or will cxplnin to parcm or legal guardinn !be rendition of patient arnlany medical risks involv~d with patient's participation in 

the wish. how to bundle medical emetg<:lwics during the wi>ilund ony spactol needs Ol' pr«autioos pt>«:d by patient's condition. If l)lllicnt is 

sunl:ring from a condition th!ll has the possibility oftronsmisslon to other pwple. I have cotll\selnd 01' will counsel parent on appropriate 

precautions. control mcusures and emef8ency proceduru. 

2. As long as parent or legal guardinn takes sufficient P"""'ution to protect patient in nccordanoc with my instructions. (o) thoro is no mcdicul 

contraindicotion to pati<:~~t'S participation in the wish. and (b) patient's participation in tl>e wish will not pt'<Scl\t sumcicnt mC<IiClll ri>ks to puticnt 

(or olberll with whom the pati<:rtt mny come into contact) to pro.ovoot my authorizing pati<:!lt to participnw in the wish. 

3. The rollowin8- modical restrictions and nands must be considered in fulfillint~the wish: 

ilinr with palioot's pby;icnl condition and certify tbat the wish Is 

~~t~l.Y----r--~~~~t·=---- cmatt 

When completed, pleose sign and fAX {215) 654· 

935410: 

Moke·A-Wish® Philodelphio & Susquehanno Valley 

5 Valley Square, Suite 210, Blue Bell. PA 19422 

AuthOrized signatories include a licensed allopathic or 

osteopathic doctor of medicine, o certified nvrse 

practitioner, or a certified physician assistant who hal 

direct knowledge of the wish child's medical condition, 
2014-11-03 11:49 

* 

· lrabots4 12155901000 7 

MAl(.E·~lSH. CHILD'S MEDICAL SUMMARY 

This form must be completed and signed by the wish child's health <ate prof.,..ionnl, Le., 

" licensed allopathic or osteopatklc dottor of medicine, n wnift!ld nurse praetitioner or • 

certified physidnn assistant who hm dire-ct knowledge of the wish ehildts medical condition~ 

Wish Child's name: Gianni McLaurin Agc/OOB: 7 I 12121/2006 

Attending Physician: Dr. Trud~ H.ae.cker 

Telephone number: (21 S) 590·1 029 

Fax number: (21~\ 590-1170 

Physician emergency number/pager: 

2. Overall current medical condition ofthc wish child: 

~t<jcR,· OIW ~ C:;W'O 

3. Will the child rl;!}uirc any of the following during the wish? 

l:ifMcdication refrigeration 0 X-Ray 0 Lab 

0 Transfusions 0 Venous aceess (physlcallocati(mltypc); ----------

0 Nursing services (please specily); ______________________ _ 

0 Oxygen (R, needed) type: Nasal Mask (spccizy rate):----------

ffi/wheelchair type: Wet cell O!y cell Collapsible 

(Jill vt.:~R. WOJ<A, ~ Wuti~ {u~J~o+ 

4. Will the child require any other medical services during the wish experience? lXJ Yes 0 No 

W;fl nw1. rwfo&w~- Wwfrftl ~ 5fL 

5. Current medications (please list type and dosage): 

6. Medications contraindicated: 

7. Allcrgics: ___ ....J.tD:!::...:·---··------------------------

Health care Professional's Sign«turo Date \ i} l ~L) Lj 

Please print name; :['tJ' Ot. ~ Ti~----

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This fonn may only be si.,ne<J by a liccn.<ed allopathic or <>'<l¢opathic doctor of medicine. a C<.'flifi!ld nurse practitioner, or a certified ph)'!'ician assistant \\llO 

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