VIP Registration

* How did you hear about Make 'm Smile?
* Who referred you?
Parent/Caregiver 1 Information
* Legal First Name:
* Legal Last Name:
* Relationship to VIP:
* Address:
Apartment/Unit #:
* City:
* State:
* Zip:
* Cell Phone:
Home Phone:
* Email:
* Comfirm Email:
Parent/Caregiver 2 Information
Legal First Name:
Legal Last Name:
Relationship to VIP:
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:
Are you new to Nathaniel's Hope? No Yes
* How many VIPs and siblings are you registering?
Child #1
* Person Type:
* Legal First Name:
* Legal Last Name:
* Gender:
* Birthday:
* VIP's Primary Diagnosis:
* 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:
* 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:
* Legal First Name:
* Legal Last Name:
* Gender:
* Birthday:
* VIP's Primary Diagnosis:
* 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:
* 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:
* Legal First Name:
* Legal Last Name:
* Gender:
* Birthday:
* VIP's Primary Diagnosis:
* 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:
* 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:
* Legal First Name:
* Legal Last Name:
* Gender:
* Birthday:
* VIP's Primary Diagnosis:
* 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:
* 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:
* Legal First Name:
* Legal Last Name:
* Gender:
* Birthday:
* VIP's Primary Diagnosis:
* 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:
* 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:
* Legal First Name:
* Legal Last Name:
* Gender:
* Birthday:
* VIP's Primary Diagnosis:
* 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:
* 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:
* Legal First Name:
* Legal Last Name:
* Gender:
* Birthday:
* VIP's Primary Diagnosis:
* 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:
* 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:
* Legal First Name:
* Legal Last Name:
* Gender:
* Birthday:
* VIP's Primary Diagnosis:
* 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:
* 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:
* Legal First Name:
* Legal Last Name:
* Gender:
* Birthday:
* VIP's Primary Diagnosis:
* 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:
* 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:
* Legal First Name:
* Legal Last Name:
* Gender:
* Birthday:
* VIP's Primary Diagnosis:
* 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:
* 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:
Ethnicity 1:
Ethnicity 2: (If same as ethnicity 1, disregard)
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.

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VIP Membership Club

Resources

VIP Families/Get a Break

Buddy/Be A Friend

Churches/Give a Break

Current Volunteer Needs

VIP Membership Club

Resources

VIP Families/Get a Break

Buddy/Be A Friend

Churches/Give a Break

Current Volunteer Needs

VIP Registration

Parent/Caregiver 1 Information

Parent/Caregiver 2 Information

Attendee Information

Child Information

Child #1

Child #2

Child #3

Child #4

Child #5

Child #6

Child #7

Child #8

Child #9

Child #10

Optional Demographic Information

Agreement (scroll down and click "I agree" to continue)