## 2014-11-03 11:49 · **~rabots4** 

## 12155901000 >" 

## We f71Hlt

## the wisbe, of cbiidren with Jife·threatenin(fmedical

## conditions tc

eMich the

### hUJ11an experience 

## with hope, strengthand joy. 

## B wos on S/16/2014 by Or. Trude Haecker. 

### This form is not intended todetermine eligibility, butrathercertifies that thechild's selected wish 

### is medically appropriate and identifies any medical restrictions 

### and precautions that must be 

### considered in granting this wish. p 

## 2/5

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 doctorofmedicine, a 

### certified nurse practitioner. 

### ora certified physician assistant who has 

### direct knowledge ofthe 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.,;, indicateyourdcterminati<m bychecking the •cmronriatsbn:<, 

### WISH IS APPROPRIATE: 

### leertiJy that

### conditions I through 

### 3hav• been 

### met. I. Ihave <:l<plnincd orwill cxplnin to parcmorlegal guardinn !berendition ofpatientarnlany medical risks
**involv~d** with patient's participation in thewish. how to bundle medical emetg<:lwics during the wi>ilund ony spactol needs Ol'pr«autioospt>«:d bypatient's condition. Ifl)lllicnt is sunl:ring from a condition th!ll has the possibility oftronsmisslon to otherpwple. Ihave cotll\selnd 01' will counsel 

### parenton appropriate precautions. control mcusures and emef8encyproceduru. 2. As long as parent orlegal guardinn takes sufficientP"""'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 (orolberll with whom the pati<:rttmny come into contact) to pro.ovootmy authorizing pati<:!ltto participnw in the wish. 3. The rollowin8- modical restrictions andnands mustbe 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 ofmedicine, 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 ofmedicine, nwnift!ld nurse praetitioner or • certified physidnn assistant who hm dire-ct knowledge ofthe 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 ofthe 

### 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~---- p 

## 3/5

This fonn may only be si.,ne<J by a liccn.<ed allopathic or<>'<l¢opathic doctor of

### medicine. aC<.'flifi!ld 

### nurse practitioner, or acertified ph)'!'ician assistant \\llO



## ~~~~~~~~~~ii~~~hf~~·~di~ **e·~hi~Ide's~nt!ld~im~mt~comn~di~Uoo~.~~~mm~~~~~~mm~~g**