Parent 1 Information 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 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
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
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
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
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
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
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
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
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
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
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
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.
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
Agreement As a VIP family for MAKE 'm SMILE, I grant permission for Nathaniel's Hope and Harvestime Apostolic Temple to use any images or video shot by event photographers and others for promotional purposes. I understand that Nathaniel's Hope and Harvestime Apostolic Temple does not pre-screen Buddies as they are Volunteers for the Friendship Stroll and Nathaniel's Hope and Harvestime Apostolic Temple is not responsible or liable for any misconduct of Buddies at the event (per Volunteer Protection Act of 1997 as amended). I understand that if my family chooses to walk with a Buddy, we are doing so at our own risk.
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