* 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:
Apt #:
* 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:
* Can we text you? Yes No
Home Phone (if different) :
* Email:
* Confirm Email:
Parent/Caregiver 2 Information (if applicable)
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 (click here)!
Child Information
* VIP(s) lives with:
Mother and Father
Mother
Father
Other Guardian/Caregiver/Group Home
* Does your VIP/Caregiver have a government issued disabled person parking permit?
Yes
No
* Please fill in permit number:
Are you new to Nathaniel's Hope?
No
Yes
* How many total VIPs and siblings are you registering?
1
2
3
4
5
6
7
8
9
10
Child #1
* Person Type:
VIP
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Shirt Size:
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
* 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
2022
2021
2020
2019
2018
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 for 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
* 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)
Photos of you child do not qualify as proof. Unrelated documents may void your registration.
Child #2
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Shirt Size:
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
* 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
2022
2021
2020
2019
2018
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 for 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
* 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)
Photos of you child do not qualify as proof. Unrelated documents may void your registration.
Child #3
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Shirt Size:
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
* 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
2022
2021
2020
2019
2018
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 for 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
* 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)
Photos of you child do not qualify as proof. Unrelated documents may void your registration.
Child #4
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Shirt Size:
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
* 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
2022
2021
2020
2019
2018
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 for 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
* 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)
Photos of you child do not qualify as proof. Unrelated documents may void your registration.
Child #5
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Shirt Size:
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
* 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
2022
2021
2020
2019
2018
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 for 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
* 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)
Photos of you child do not qualify as proof. Unrelated documents may void your registration.
Child #6
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Shirt Size:
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
* 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
2022
2021
2020
2019
2018
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 for 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
* 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)
Photos of you child do not qualify as proof. Unrelated documents may void your registration.
Child #7
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Shirt Size:
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
* 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
2022
2021
2020
2019
2018
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 for 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
* 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)
Photos of you child do not qualify as proof. Unrelated documents may void your registration.
Child #8
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Shirt Size:
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
* 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
2022
2021
2020
2019
2018
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
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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 for 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
* 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)
Photos of you child do not qualify as proof. Unrelated documents may void your registration.
Child #9
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Shirt Size:
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
* 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
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
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1994
1993
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1991
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1984
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1936
1935
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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 for 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
* 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)
Photos of you child do not qualify as proof. Unrelated documents may void your registration.
Child #10
* Person Type:
VIP
Sibling
* Legal First Name:
* Legal Last Name:
* Gender:
Male
Female
* Shirt Size:
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
* 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
2022
2021
2020
2019
2018
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 for 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
* 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)
Photos of you child do not qualify as proof. Unrelated documents may void your registration.
2023 Make 'm Smile shirts are available while supplies last. Sizes are not guaranteed.
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
Acknowledgement, Release & Waiver (scroll down and click "I agree" to continue)
By Participating in this event, and submitting this VIP Family registration, you are acknowledging the following:
Release: VIP Family is participating in Make 'm Smile ("Activity") voluntarily, and does hereby release and forever discharge and hold harmless Nathaniel's Hope and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from VIP Family's participation in the Activity. VIP Family understands that this release discharges Nathaniel's Hope from any liability or claim that VIP Family may have against Nathaniel's Hope with respect to any bodily injury, personal injury, illness, death or property damage that may result from VIP Family's participation with the Activity, whether caused by the gross negligence of Nathaniel's Hope or its officers, directors, employees, agents, or otherwise. VIP Family also understands that Nathaniel's Hope does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness. VIP Family understands that, except as otherwise agreed to by Nathaniel's Hope in writing; Nathaniel's Hope does not carry or maintain health, medical, or disability insurance coverage for any VIP Family. Each VIP Family is expected and encouraged to obtain his or her own medical or health insurance coverage.
Other: VIP Family understands 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.
Photographic Release: VIP Family does hereby grant and convey unto Nathaniel's Hope all right, title, and interest in any and all photographic images and video or audio recordings made by Nathaniel's Hope during the VIP Family's Participation in the Activity, including but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings. Other: VIP Family expressly agrees that this Release is intended to be as broad and inclusive as permitted by laws of the State of Florida, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Florida. VIP Family agrees that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provision of this Release which shall continue to be enforceable.
With your registration, you agree that:
You will not attend the event if you have:
(a) experienced COVID-19 symptoms in the past 5 days,
(b) received a positive COVID-19 test in the 5 days prior to the event, and
(c) did not come in contact or close proximity with a confirmed or suspected COVID-19 case in the 5 days prior to the event.
You will comply with all facility and event safety and health protocols regarding COVID-19 and/or any other communicable and/or infectious diseases, viruses, bacteria or illnesses or the causes thereof, as determined to be applicable by the Florida Department of Health. If the event is held in conjunction with another facility or group (“outside groups”), you agree to comply with any additional protocols put in place by these outside groups. Any applicable safety and health protocols will be communicated prior to the event.
Nathaniel’s Hope, Inc. has the right to deny admission to or reject any person whom the event organizers determine to pose a risk to the health or safety of others and/or whose conduct violates these terms of the event policies and procedures.
Participation in this event carries with it certain inherent risks related to COVID-19 transmission. By voluntarily attending this event, you accept and assume all risk of loss, personal injury, sickness, death, damage, and expense arising from these inherent risks
I affirm that I have read and agree to all information in this waiver.
By Using the Event Essentials System you agree for Event Essentials to use your personal information to complete the Purchase, Donation, and/or Registration. For more information click here .