KMBC Dream Factory Form

Dream Factory Nomination Form
KMBC is a proud sponsor of the Dream Factory. Since 1985 the Dream Factory has been dedicated to making dreams come true for chronically or critically ill children between the ages of 3 and 18 years old. The Dream Factory is a 100 percent volunteer organization. Do you know a child who may be eligible to receive a dream? If so, please fill in the information below. We would like to make many more dreams come true! For more information about the Dream Factory, to donate or to volunteer, click here.

Your Name *This question is required.

Your Email Address *This question is required.

Your Phone Number (Home or Cell) *This question is required.

Child's Name *This question is required.

Child's Age *This question is required.

Child's Illness *This question is required.

Child's Parent/Guardian Name(s) *This question is required.

Parent/Guardian's Phone Number(s) (Home or Cell) *This question is required.

Parent/Guardian's Email(s) *This question is required.

Parent/Guardian's Street Address *This question is required.

Parent/Guardian's City *This question is required.

Parent/Guardian's Zip Code *This question is required.

Comments about the child (such as child's current medical condition) *This question is required.