Parent 1 Information Parent/Guardian Name*
Legal First Name
Legal Last Name
Relationship to VIP(s)* Mother Father Guardian/Caregiver/Group Home
If with a Group Home, please provide Home name below:
Birthdate* Address*
Cell Phone*
Home Phone (if different from cell phone)
Email* Parent 2 Information Parent/Guardian Name
Legal First Name
Legal Last Name
Relationship to VIP(s) Mother Father Guardian/Caregiver/Group Home
Email Cell Phone
VIP(s) reside with:* Mother and Father Father Mother Other caregiver/guardian/group house
How did you hear about Make 'm Smile?*
CHILD INFORMATION How many VIPs and siblings are you registering?* 1 2 3 4 5 6 7 8 9 10
Child #1 Child #1 must be a VIP.
Person Type VIP
VIP's Name*
Legal First Name
Legal Last Name
Gender* Male Female
Birthday* 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
This VIP attends Buddy Break Yes No
This VIP attends Buddy Break at: Calvary Community Church Emmanuel Church Gold Coast Christian Church The Bridge Other:
If you selected other, please provide the name of your Buddy Break Church
Did this VIP receive a VIP Membership ID # ?* No Yes
If you registered and verified this child as a VIP with Nathaniel's Hope you should have received a VIP Membership ID #. If you did not receive it, you will need to upload proof of disability for this event.
Child #1 VIP Membership ID #*
Acceptable Proof of Disability (You must upload one of the following):* IEP (only first page with VIP's name & diagnosis) Official letter from doctor on letterhead Official letter from licensed therapist on letterhead SSI Letter
These are the only documents that we now accept as proof of disability. The document that you upload must be current with the VIP's name, birth-date, and diagnosis explicitly stated. (Photos of your VIP will not be accepted as proof of disability)
Please upload Proof of Disability (type chosen above).* This is required even if you have previously submitted proof. *IF YOU ARE HAVING DIFFICULTY, THE FILE SIZE MAY BE TOO BIG.
Child #2 Person Type* VIP Sibling
Name*
Legal First Name
Legal Last Name
Gender* Male Female
Birthday* 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
This VIP attends Buddy Break Yes No
This VIP attends Buddy Break at: Calvary Community Church Emmanuel Church Gold Coast Christian Church The Bridge Other:
If you selected other, please provide the name of your Buddy Break Church
Did this VIP receive a VIP Membership ID # ?* No Yes
If you registered and verified this child as a VIP with Nathaniel's Hope you should have received a VIP Membership ID #. If you did not receive it, you will need to upload proof of disability for this event.
Child #2 VIP Membership ID #*
Acceptable Proof of Disability (You must upload one of the following):* IEP (only first page with VIP's name & diagnosis) Official letter from doctor on letterhead Official letter from licensed therapist on letterhead SSI Letter
These are the only documents that we now accept as proof of disability. The document that you upload must be current with the VIP's name, birth-date, and diagnosis explicitly stated.
(Photos of your VIP will not be accepted as proof of disability)
Please upload Proof of Disability (type chosen above)* This is required even if you have previously submitted proof. *IF YOU ARE HAVING DIFFICULTY, THE FILE SIZE MAY BE TOO BIG.
Child #3 Person Type* VIP Sibling
Name*
Legal First Name
Legal Last Name
Gender* Male Female
Birthday* 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
This VIP attends Buddy Break Yes No
This VIP attends Buddy Break at: Calvary Community Church Emmanuel Church Gold Coast Christian Church The Bridge Other:
If you selected other, please provide the name of your Buddy Break Church
Did this VIP receive a VIP Membership ID # ?* No Yes
If you registered and verified this child as a VIP with Nathaniel's Hope you should have received a VIP Membership ID #. If you did not receive it, you will need to upload proof of disability for this event.
Child #3 VIP Membership ID #*
Acceptable Proof of Disability (You must upload one of the following):* IEP (only first page with VIP's name & diagnosis) Official letter from doctor on letterhead Official letter from licensed therapist on letterhead SSI Letter
These are the only documents that we now accept as proof of disability. The document that you upload must be current with the VIP's name, birth-date, and diagnosis explicitly stated.
(Photos of your VIP will not be accepted as proof of disability)
Please upload Proof of Disability (type chosen above)* This is required even if you have previously submitted proof. *IF YOU ARE HAVING DIFFICULTY, THE FILE SIZE MAY BE TOO BIG.
Child #4 Person Type* VIP Sibling
Name*
Legal First Name
Legal Last Name
Gender* Male Female
Birthday* 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
This VIP attends Buddy Break Yes No
This VIP attends Buddy Break at: Calvary Community Church Emmanuel Church Gold Coast Christian Church The Bridge Other:
If you selected other, please provide the name of your Buddy Break Church
Did this VIP receive a VIP Membership ID # ?* No Yes
If you registered and verified this child as a VIP with Nathaniel's Hope you should have received a VIP Membership ID #. If you did not receive it, you will need to upload proof of disability for this event.
Child #4 VIP Membership ID #*
Acceptable Proof of Disability (You must upload one of the following):* IEP (only first page with VIP's name & diagnosis) Official letter from doctor on letterhead Official letter from licensed therapist on letterhead SSI Letter
These are the only documents that we now accept as proof of disability. The document that you upload must be current with the VIP's name, birth-date, and diagnosis explicitly stated.
(Photos of your VIP will not be accepted as proof of disability)
Please upload Proof of Disability (type chosen above)* This is required even if you have previously submitted proof. *IF YOU ARE HAVING DIFFICULTY, THE FILE SIZE MAY BE TOO BIG.
Child #5 Person Type* VIP Sibling
Name*
Legal First Name
Legal Last Name
Gender* Male Female
Birthday* 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
This VIP attends Buddy Break Yes No
This VIP attends Buddy Break at: Calvary Community Church Emmanuel Church Gold Coast Christian Church The Bridge Other:
If you selected other, please provide the name of your Buddy Break Church
Did this VIP receive a VIP Membership ID # ?* No Yes
If you registered and verified this child as a VIP with Nathaniel's Hope you should have received a VIP Membership ID #. If you did not receive it, you will need to upload proof of disability for this event.
Child #5 VIP Membership ID #*
Acceptable Proof of Disability (You must upload one of the following):* IEP (only first page with VIP's name & diagnosis) Official letter from doctor on letterhead Official letter from licensed therapist on letterhead SSI Letter
These are the only documents that we now accept as proof of disability. The document that you upload must be current with the VIP's name, birth-date, and diagnosis explicitly stated.
(Photos of your VIP will not be accepted as proof of disability)
Please upload Proof of Disability (type chosen above)* This is required even if you have previously submitted proof. *IF YOU ARE HAVING DIFFICULTY, THE FILE SIZE MAY BE TOO BIG.
Child #6 Person Type* VIP Sibling
Name*
Legal First Name
Legal Last Name
Gender* Male Female
Birthday* 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
This VIP attends Buddy Break Yes No
This VIP attends Buddy Break at: Calvary Community Church Emmanuel Church Gold Coast Christian Church The Bridge Other:
If you selected other, please provide the name of your Buddy Break Church
Did this VIP receive a VIP Membership ID # ?* No Yes
If you registered and verified this child as a VIP with Nathaniel's Hope you should have received a VIP Membership ID #. If you did not receive it, you will need to upload proof of disability for this event.
Child #6 VIP Membership ID #*
Acceptable Proof of Disability (You must upload one of the following):* IEP (only first page with VIP's name & diagnosis) Official letter from doctor on letterhead Official letter from licensed therapist on letterhead SSI Letter
These are the only documents that we now accept as proof of disability. The document that you upload must be current with the VIP's name, birth-date, and diagnosis explicitly stated.
(Photos of your VIP will not be accepted as proof of disability)
Please upload Proof of Disability (type chosen above)* This is required even if you have previously submitted proof. *IF YOU ARE HAVING DIFFICULTY, THE FILE SIZE MAY BE TOO BIG.
Child #7 Person Type* VIP Sibling
Name*
Legal First Name
Legal Last Name
Gender* Male Female
Birthday* 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
This VIP attends Buddy Break Yes No
This VIP attends Buddy Break at: Calvary Community Church Emmanuel Church Gold Coast Christian Church The Bridge Other:
If you selected other, please provide the name of your Buddy Break Church
Did this VIP receive a VIP Membership ID # ?* No Yes
If you registered and verified this child as a VIP with Nathaniel's Hope you should have received a VIP Membership ID #. If you did not receive it, you will need to upload proof of disability for this event.
Child #7 VIP Membership ID #*
Acceptable Proof of Disability (You must upload one of the following):* IEP (only first page with VIP's name & diagnosis) Official letter from doctor on letterhead Official letter from licensed therapist on letterhead SSI Letter
These are the only documents that we now accept as proof of disability. The document that you upload must be current with the VIP's name, birth-date, and diagnosis explicitly stated.
(Photos of your VIP will not be accepted as proof of disability)
Please upload Proof of Disability (type chosen above)* This is required even if you have previously submitted proof. *IF YOU ARE HAVING DIFFICULTY, THE FILE SIZE MAY BE TOO BIG.
Child #8 Person Type* VIP Sibling
Name*
Legal First Name
Legal Last Name
Gender* Male Female
Birthday* 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
This VIP attends Buddy Break Yes No
This VIP attends Buddy Break at: Calvary Community Church Emmanuel Church Gold Coast Christian Church The Bridge Other:
If you selected other, please provide the name of your Buddy Break Church
Did this VIP receive a VIP Membership ID # ?* No Yes
If you registered and verified this child as a VIP with Nathaniel's Hope you should have received a VIP Membership ID #. If you did not receive it, you will need to upload proof of disability for this event.
Child #8 VIP Membership ID #*
Acceptable Proof of Disability (You must upload one of the following):* IEP (only first page with VIP's name & diagnosis) Official letter from doctor on letterhead Official letter from licensed therapist on letterhead SSI Letter
These are the only documents that we now accept as proof of disability. The document that you upload must be current with the VIP's name, birth-date, and diagnosis explicitly stated. (Photos of your VIP will not be accepted as proof of disability)
Please upload Proof of Disability (type chosen above)* This is required even if you have previously submitted proof. *IF YOU ARE HAVING DIFFICULTY, THE FILE SIZE MAY BE TOO BIG.
Child #9 Person Type* VIP Sibling
Name*
Legal First Name
Legal Last Name
Gender* Male Female
Birthday* 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
This VIP attends Buddy Break Yes No
This VIP attends Buddy Break at: Calvary Community Church Emmanuel Church Gold Coast Christian Church The Bridge Other:
If you selected other, please provide the name of your Buddy Break Church
Did this VIP receive a VIP Membership ID # ?* No Yes
If you registered and verified this child as a VIP with Nathaniel's Hope you should have received a VIP Membership ID #. If you did not receive it, you will need to upload proof of disability for this event.
Child #9 VIP Membership ID #*
Acceptable Proof of Disability (You must upload one of the following):* IEP (only first page with VIP's name & diagnosis) Official letter from doctor on letterhead Official letter from licensed therapist on letterhead SSI Letter
These are the only documents that we now accept as proof of disability. The document that you upload must be current with the VIP's name, birth-date, and diagnosis explicitly stated. (Photos of your VIP will not be accepted as proof of disability)
Please upload Proof of Disability (type chosen above)* This is required even if you have previously submitted proof. *IF YOU ARE HAVING DIFFICULTY, THE FILE SIZE MAY BE TOO BIG.
Child #10 Person Type* VIP Sibling
Name*
Legal First Name
Legal Last Name
Gender* Male Female
Birthday* 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
This VIP attends Buddy Break Yes No
This VIP attends Buddy Break at: Calvary Community Church Emmanuel Church Gold Coast Christian Church The Bridge Other:
If you selected other, please provide the name of your Buddy Break Church
Did this VIP receive a VIP Membership ID # ?* No Yes
If you registered and verified this child as a VIP with Nathaniel's Hope you should have received a VIP Membership ID #. If you did not receive it, you will need to upload proof of disability for this event.
Child #10 VIP Membership ID #*
Acceptable Proof of Disability (You must upload one of the following):* IEP (only first page with VIP's name & diagnosis) Official letter from doctor on letterhead Official letter from licensed therapist on letterhead SSI Letter
These are the only documents that we now accept as proof of disability. The document that you upload must be current with the VIP's name, birth-date, and diagnosis explicitly stated. (Photos of your VIP will not be accepted as proof of disability)
Please upload Proof of Disability (type chosen above)* This is required even if you have previously submitted proof. *IF YOU ARE HAVING DIFFICULTY, THE FILE SIZE MAY BE TOO BIG.
Credit Card Hold To Reserve Your Spot A $20 Credit Card hold is required to reserve your spot. This amount will be removed after we verify your attendance at Make 'm Smile or by cancelling your reservation by
August 23, 2022.
Confirmation Deposit*
Price:
Nathaniel's Hope Make 'm Smile Credit Card Policy: Activities are planned based on a limited number of tickets. In order for us to secure your registration to the event, we require your authorization for a $20 hold on a valid Credit Card. Submitting this form will AUTHORIZE a $20 HOLD on your credit card. Your card will ONLY be charged the $20 fee if you DO NOT attend the event, or DO NOT cancel your ticket reservation by Tuesday, August 23, 2022, by 12:00 noon. You will see a temporary $20 Hold on your card, but this will be removed AFTER the event (Including those that have canceled prior to August 24th) when we verify your attendance on August 27, 2022. The time release of the Hold will depend on your Bank's Policy for posting funds to your account.
This $20 Hold will NOT be applied to the purchase of any additional discounted tickets.
Total
$0.00
Credit Card* Billing Address*
As it appears on billing statement.
Acknowledgement, Release & Waiver By Participating in this event, and submitting this VIP Family registration, you are acknowledging the following:
Release* Photographic Release* Name*
By signing this registration, I affirm that I have read and agree to all information in this waiver.
Date*
MM slash DD slash YYYY
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.
Will you help us by providing optional demographic information?* Yes No
Family Income Level: <$20,000 $20,001-$30,000 $30,001-$40,000 $40,001-$50,000 $50,001-$60,000 >$60,001 non-paid
Ethnicity 1 African-American/Black American Indian or Alaska Native Arab Asian Indian Caucasian/White Chinese Filipino Guamanian or Chamorro Haitian Hispanic/Latino/Latina Japanese Korean Pacific Islander Vietnamese Other
Ethnicity 2 African-American/Black American Indian or Alaska Native Arab Asian Indian Caucasian/White Chinese Filipino Guamanian or Chamorro Haitian Hispanic/Latino/Latina Japanese Korean Pacific Islander Vietnamese Other
Phone
This field is for validation purposes and should be left unchanged.
