* How did you hear about Make 'm Smile?
Social Media
Buddy Break
E-mail
TV
Radio
Attended in the past
Billboard
School Flyer
Poster
Friend/Family
Other
* Who referred you?
Parent/Caregiver 1 Information
* Legal First Name:
* Legal Last Name:
* Relationship to VIP:
Mother
Father
Guardian/Caregiver/Group Home
* Address:
Apartment/Unit #:
* City:
* State:
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
* Zip:
* Cell Phone:
Home Phone:
* Email:
* Comfirm Email:
Parent/Caregiver 2 Information
Legal First Name:
Legal Last Name:
Relationship to VIP:
Mother
Father
Guardian/Caregiver/Group Home
Email:
Comfirm Email:
Cell Phone:
Attendee Information
Wristbands are provided FREE to kids with special needs and their parents/siblings! Extended family (aunts, uncles, cousins, grandparents) and friends can get wristbands for $5 each at the event or online by registering as a Buddy!
Child Information
* VIP(s) lives with:
Mother and Father
Mother
Father
Other Guardian/Caregiver/Group Home
Are you new to Nathaniel's Hope?
No
Yes
* How many VIPs and siblings are you registering?
1
2
3
4
5
6
7
8
9
10
Child #1
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Birthday:
mm
1
2
3
4
5
6
7
8
9
10
11
12
dd
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
yyyy
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1959
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1957
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1953
1952
1951
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1949
1948
1947
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1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
* VIP's Primary Diagnosis:
Auditory Processing Disorder
Autism Spectrum
Bipolar
Cerebral Palsy
Chronic Condition
Congenital Disorder
Developmental Delay
Down Syndrome
Epilepsy/Seizure Disorder
Hearing Impairment
Intellectual/Cognitive Disability
Learning Disability
Life Threatening Illness
Medical Disability
Medically Fragile
Mental Health Issue
Mood/Behavior/Anxiety/Emotional Disorder
Musculoskeletal Impariment
Neurological Impairment
Physical Disability
Respiratory/Pulmonary Impairment
Sensory Processing Disorder
Speech/Language Impairment
Visual Impairment
Other Syndrome/Special Need
ADD/ADHD
* Did this VIP receive a VIP Membership ID #? (If this child is registered and verified as a VIP with Nathaniel's Hope, you should have received a VIP Membership ID #. If you do not have one, you will need to upload proof of disability at this event.)
Yes
No
* Child #1 VIP Membership ID #:
* Acceptable Proof of Disability:
IEP (only first page with VIP's name and diagnosis)
504 Plan
Official letter from a doctor/therapist on letterhead
SSI disability letter for the VIP
* Please upload Proof of Disability (type chosen above) (If you are having difficulty, the file size may be too big.)
(supported file types: JPG/GIF/PNG/PDF/DOC, max file size: 5MB)
Child #2
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Birthday:
mm
1
2
3
4
5
6
7
8
9
10
11
12
dd
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
yyyy
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
* VIP's Primary Diagnosis:
Auditory Processing Disorder
Autism Spectrum
Bipolar
Cerebral Palsy
Chronic Condition
Congenital Disorder
Developmental Delay
Down Syndrome
Epilepsy/Seizure Disorder
Hearing Impairment
Intellectual/Cognitive Disability
Learning Disability
Life Threatening Illness
Medical Disability
Medically Fragile
Mental Health Issue
Mood/Behavior/Anxiety/Emotional Disorder
Musculoskeletal Impariment
Neurological Impairment
Physical Disability
Respiratory/Pulmonary Impairment
Sensory Processing Disorder
Speech/Language Impairment
Visual Impairment
Other Syndrome/Special Need
ADD/ADHD
* Did this VIP receive a VIP Membership ID #? (If this child is registered and verified as a VIP with Nathaniel's Hope, you should have received a VIP Membership ID #. If you do not have one, you will need to upload proof of disability at this event.)
Yes
No
* Child #2 VIP Membership ID #:
* Acceptable Proof of Disability:
IEP (only first page with VIP's name and diagnosis)
504 Plan
Official letter from a doctor/therapist on letterhead
SSI disability letter for the VIP
* Please upload Proof of Disability (type chosen above) (If you are having difficulty, the file size may be too big.)
(supported file types: JPG/GIF/PNG/PDF/DOC, max file size: 5MB)
Child #3
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Birthday:
mm
1
2
3
4
5
6
7
8
9
10
11
12
dd
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
yyyy
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
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1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
* VIP's Primary Diagnosis:
Auditory Processing Disorder
Autism Spectrum
Bipolar
Cerebral Palsy
Chronic Condition
Congenital Disorder
Developmental Delay
Down Syndrome
Epilepsy/Seizure Disorder
Hearing Impairment
Intellectual/Cognitive Disability
Learning Disability
Life Threatening Illness
Medical Disability
Medically Fragile
Mental Health Issue
Mood/Behavior/Anxiety/Emotional Disorder
Musculoskeletal Impariment
Neurological Impairment
Physical Disability
Respiratory/Pulmonary Impairment
Sensory Processing Disorder
Speech/Language Impairment
Visual Impairment
Other Syndrome/Special Need
ADD/ADHD
* Did this VIP receive a VIP Membership ID #? (If this child is registered and verified as a VIP with Nathaniel's Hope, you should have received a VIP Membership ID #. If you do not have one, you will need to upload proof of disability at this event.)
Yes
No
* Child #3 VIP Membership ID #:
* Acceptable Proof of Disability:
IEP (only first page with VIP's name and diagnosis)
504 Plan
Official letter from a doctor/therapist on letterhead
SSI disability letter for the VIP
* Please upload Proof of Disability (type chosen above) (If you are having difficulty, the file size may be too big.)
(supported file types: JPG/GIF/PNG/PDF/DOC, max file size: 5MB)
Child #4
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Birthday:
mm
1
2
3
4
5
6
7
8
9
10
11
12
dd
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
yyyy
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
* VIP's Primary Diagnosis:
Auditory Processing Disorder
Autism Spectrum
Bipolar
Cerebral Palsy
Chronic Condition
Congenital Disorder
Developmental Delay
Down Syndrome
Epilepsy/Seizure Disorder
Hearing Impairment
Intellectual/Cognitive Disability
Learning Disability
Life Threatening Illness
Medical Disability
Medically Fragile
Mental Health Issue
Mood/Behavior/Anxiety/Emotional Disorder
Musculoskeletal Impariment
Neurological Impairment
Physical Disability
Respiratory/Pulmonary Impairment
Sensory Processing Disorder
Speech/Language Impairment
Visual Impairment
Other Syndrome/Special Need
ADD/ADHD
* Did this VIP receive a VIP Membership ID #? (If this child is registered and verified as a VIP with Nathaniel's Hope, you should have received a VIP Membership ID #. If you do not have one, you will need to upload proof of disability at this event.)
Yes
No
* Child #4 VIP Membership ID #:
* Acceptable Proof of Disability:
IEP (only first page with VIP's name and diagnosis)
504 Plan
Official letter from a doctor/therapist on letterhead
SSI disability letter for the VIP
* Please upload Proof of Disability (type chosen above) (If you are having difficulty, the file size may be too big.)
(supported file types: JPG/GIF/PNG/PDF/DOC, max file size: 5MB)
Child #5
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Birthday:
mm
1
2
3
4
5
6
7
8
9
10
11
12
dd
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
yyyy
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
* VIP's Primary Diagnosis:
Auditory Processing Disorder
Autism Spectrum
Bipolar
Cerebral Palsy
Chronic Condition
Congenital Disorder
Developmental Delay
Down Syndrome
Epilepsy/Seizure Disorder
Hearing Impairment
Intellectual/Cognitive Disability
Learning Disability
Life Threatening Illness
Medical Disability
Medically Fragile
Mental Health Issue
Mood/Behavior/Anxiety/Emotional Disorder
Musculoskeletal Impariment
Neurological Impairment
Physical Disability
Respiratory/Pulmonary Impairment
Sensory Processing Disorder
Speech/Language Impairment
Visual Impairment
Other Syndrome/Special Need
ADD/ADHD
* Did this VIP receive a VIP Membership ID #? (If this child is registered and verified as a VIP with Nathaniel's Hope, you should have received a VIP Membership ID #. If you do not have one, you will need to upload proof of disability at this event.)
Yes
No
* Child #5 VIP Membership ID #:
* Acceptable Proof of Disability:
IEP (only first page with VIP's name and diagnosis)
504 Plan
Official letter from a doctor/therapist on letterhead
SSI disability letter for the VIP
* Please upload Proof of Disability (type chosen above) (If you are having difficulty, the file size may be too big.)
(supported file types: JPG/GIF/PNG/PDF/DOC, max file size: 5MB)
Child #6
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Birthday:
mm
1
2
3
4
5
6
7
8
9
10
11
12
dd
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
yyyy
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
* VIP's Primary Diagnosis:
Auditory Processing Disorder
Autism Spectrum
Bipolar
Cerebral Palsy
Chronic Condition
Congenital Disorder
Developmental Delay
Down Syndrome
Epilepsy/Seizure Disorder
Hearing Impairment
Intellectual/Cognitive Disability
Learning Disability
Life Threatening Illness
Medical Disability
Medically Fragile
Mental Health Issue
Mood/Behavior/Anxiety/Emotional Disorder
Musculoskeletal Impariment
Neurological Impairment
Physical Disability
Respiratory/Pulmonary Impairment
Sensory Processing Disorder
Speech/Language Impairment
Visual Impairment
Other Syndrome/Special Need
ADD/ADHD
* Did this VIP receive a VIP Membership ID #? (If this child is registered and verified as a VIP with Nathaniel's Hope, you should have received a VIP Membership ID #. If you do not have one, you will need to upload proof of disability at this event.)
Yes
No
* Child #6 VIP Membership ID #:
* Acceptable Proof of Disability:
IEP (only first page with VIP's name and diagnosis)
504 Plan
Official letter from a doctor/therapist on letterhead
SSI disability letter for the VIP
* Please upload Proof of Disability (type chosen above) (If you are having difficulty, the file size may be too big.)
(supported file types: JPG/GIF/PNG/PDF/DOC, max file size: 5MB)
Child #7
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Birthday:
mm
1
2
3
4
5
6
7
8
9
10
11
12
dd
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
yyyy
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
* VIP's Primary Diagnosis:
Auditory Processing Disorder
Autism Spectrum
Bipolar
Cerebral Palsy
Chronic Condition
Congenital Disorder
Developmental Delay
Down Syndrome
Epilepsy/Seizure Disorder
Hearing Impairment
Intellectual/Cognitive Disability
Learning Disability
Life Threatening Illness
Medical Disability
Medically Fragile
Mental Health Issue
Mood/Behavior/Anxiety/Emotional Disorder
Musculoskeletal Impariment
Neurological Impairment
Physical Disability
Respiratory/Pulmonary Impairment
Sensory Processing Disorder
Speech/Language Impairment
Visual Impairment
Other Syndrome/Special Need
ADD/ADHD
* Did this VIP receive a VIP Membership ID #? (If this child is registered and verified as a VIP with Nathaniel's Hope, you should have received a VIP Membership ID #. If you do not have one, you will need to upload proof of disability at this event.)
Yes
No
* Child #7 VIP Membership ID #:
* Acceptable Proof of Disability:
IEP (only first page with VIP's name and diagnosis)
504 Plan
Official letter from a doctor/therapist on letterhead
SSI disability letter for the VIP
* Please upload Proof of Disability (type chosen above) (If you are having difficulty, the file size may be too big.)
(supported file types: JPG/GIF/PNG/PDF/DOC, max file size: 5MB)
Child #8
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Birthday:
mm
1
2
3
4
5
6
7
8
9
10
11
12
dd
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
yyyy
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
* VIP's Primary Diagnosis:
Auditory Processing Disorder
Autism Spectrum
Bipolar
Cerebral Palsy
Chronic Condition
Congenital Disorder
Developmental Delay
Down Syndrome
Epilepsy/Seizure Disorder
Hearing Impairment
Intellectual/Cognitive Disability
Learning Disability
Life Threatening Illness
Medical Disability
Medically Fragile
Mental Health Issue
Mood/Behavior/Anxiety/Emotional Disorder
Musculoskeletal Impariment
Neurological Impairment
Physical Disability
Respiratory/Pulmonary Impairment
Sensory Processing Disorder
Speech/Language Impairment
Visual Impairment
Other Syndrome/Special Need
ADD/ADHD
* Did this VIP receive a VIP Membership ID #? (If this child is registered and verified as a VIP with Nathaniel's Hope, you should have received a VIP Membership ID #. If you do not have one, you will need to upload proof of disability at this event.)
Yes
No
* Child #8 VIP Membership ID #:
* Acceptable Proof of Disability:
IEP (only first page with VIP's name and diagnosis)
504 Plan
Official letter from a doctor/therapist on letterhead
SSI disability letter for the VIP
* Please upload Proof of Disability (type chosen above) (If you are having difficulty, the file size may be too big.)
(supported file types: JPG/GIF/PNG/PDF/DOC, max file size: 5MB)
Child #9
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Birthday:
mm
1
2
3
4
5
6
7
8
9
10
11
12
dd
1
2
3
4
5
6
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31
yyyy
2017
2016
2015
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2012
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1918
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1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
* VIP's Primary Diagnosis:
Auditory Processing Disorder
Autism Spectrum
Bipolar
Cerebral Palsy
Chronic Condition
Congenital Disorder
Developmental Delay
Down Syndrome
Epilepsy/Seizure Disorder
Hearing Impairment
Intellectual/Cognitive Disability
Learning Disability
Life Threatening Illness
Medical Disability
Medically Fragile
Mental Health Issue
Mood/Behavior/Anxiety/Emotional Disorder
Musculoskeletal Impariment
Neurological Impairment
Physical Disability
Respiratory/Pulmonary Impairment
Sensory Processing Disorder
Speech/Language Impairment
Visual Impairment
Other Syndrome/Special Need
ADD/ADHD
* Did this VIP receive a VIP Membership ID #? (If this child is registered and verified as a VIP with Nathaniel's Hope, you should have received a VIP Membership ID #. If you do not have one, you will need to upload proof of disability at this event.)
Yes
No
* Child #9 VIP Membership ID #:
* Acceptable Proof of Disability:
IEP (only first page with VIP's name and diagnosis)
504 Plan
Official letter from a doctor/therapist on letterhead
SSI disability letter for the VIP
* Please upload Proof of Disability (type chosen above) (If you are having difficulty, the file size may be too big.)
(supported file types: JPG/GIF/PNG/PDF/DOC, max file size: 5MB)
Child #10
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Birthday:
mm
1
2
3
4
5
6
7
8
9
10
11
12
dd
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
yyyy
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
* VIP's Primary Diagnosis:
Auditory Processing Disorder
Autism Spectrum
Bipolar
Cerebral Palsy
Chronic Condition
Congenital Disorder
Developmental Delay
Down Syndrome
Epilepsy/Seizure Disorder
Hearing Impairment
Intellectual/Cognitive Disability
Learning Disability
Life Threatening Illness
Medical Disability
Medically Fragile
Mental Health Issue
Mood/Behavior/Anxiety/Emotional Disorder
Musculoskeletal Impariment
Neurological Impairment
Physical Disability
Respiratory/Pulmonary Impairment
Sensory Processing Disorder
Speech/Language Impairment
Visual Impairment
Other Syndrome/Special Need
ADD/ADHD
* Did this VIP receive a VIP Membership ID #? (If this child is registered and verified as a VIP with Nathaniel's Hope, you should have received a VIP Membership ID #. If you do not have one, you will need to upload proof of disability at this event.)
Yes
No
* Child #10 VIP Membership ID #:
* Acceptable Proof of Disability:
IEP (only first page with VIP's name and diagnosis)
504 Plan
Official letter from a doctor/therapist on letterhead
SSI disability letter for the VIP
* Please upload Proof of Disability (type chosen above) (If you are having difficulty, the file size may be too big.)
(supported file types: JPG/GIF/PNG/PDF/DOC, max file size: 5MB)
Optional Demographic Information
(When applying for grants, we are asked for certain information. By responding to these optional questions, you will be helping us in gathering funds for Nathaniel's Hope.)
Family Income Level:
Non-Paid
<$20,000
$20,001-30,000
$30,001-40,000
$40,001-50,000
$50,001-60,000
>$60,001
Ethnicity 1:
African-American/Black
American Indian or Alaska Native
Arab/Middle Eastern
Asian Indian
Caucasian/White
Chinese
Filipino
Guamanian or Chamorro
Haitian
Hispanic/Latino/Latina
Japanese
Korean
Pacific Islander
Vietnamese
Other
Ethnicity 2: (If same as ethnicity 1, disregard)
African-American/Black
American Indian or Alaska Native
Arab/Middle Eastern
Asian Indian
Caucasian/White
Chinese
Filipino
Guamanian or Chamorro
Haitian
Hispanic/Latino/Latina
Japanese
Korean
Pacific Islander
Vietnamese
Other
Agreement (scroll down and click "I agree" to continue)
As a VIP family for Make 'm Smile, I grant permission for Nathaniel's Hope to use any images or video shot by Nathaniel's Hope event photographers and others for promotional purposes. I understand that Nathaniel's Hope does not pre-screen Buddies as they are Volunteers for the Friendship Stroll and Nathaniel's Hope is not responsible or liable for any misconduct of Buddies at the event (per Volunteer Protection Act of 1997 as awarded). I understand that if my family chooses to walk with a Buddy, we are doing so at our own risk.
I affirm that I have read and agree to all information in this waiver.