MAKE 'm SMILE Ohio VIP Registration

Ohio MAKE 'm SMILE VIP Registration

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Parent 1 Information

Name*

Legal First Name Legal Last Name

Relationship to VIP(s)*

If with a Group Home, please provide Home name below:

Birthdate*

Address*

Street Address Apartment/Unit # (if applicable) City State ZIP Code

Cell Phone*

Home Phone (if different from cell phone)

Email*

Enter Email Confirm Email

Parent 2 Information

Name

Legal First Name Legal Last Name

Relationship to VIP(s)

Enter Email Confirm Email

Cell Phone

VIP(s) reside with:*

CHILD INFORMATION

How many VIPs and siblings are you registering?*

Child #1

Child #1 must be a VIP.

Person Type*

VIP's Name*

Legal First Name Legal Last Name

Gender*

Birthday*

Primary Diagnosis*

Did this VIP receive a VIP Membership ID # ?*

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):*

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)*

Max. file size: 800 MB.

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*

Name*

Legal First Name Legal Last Name

Gender*

Birthday*

Primary Diagnosis*

Did this VIP receive a VIP Membership ID # ?*

Child #2 VIP Membership ID #*

Acceptable Proof of Disability (You must upload one of the following):*

Please upload Proof of Disability (type chosen above)*

Max. file size: 800 MB.

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*

Name*

Legal First Name Legal Last Name

Gender*

Birthday*

Primary Diagnosis*

Did this VIP receive a VIP Membership ID # ?*

Child #3 VIP Membership ID #*

Acceptable Proof of Disability (You must upload one of the following):*

Please upload Proof of Disability (type chosen above)*

Max. file size: 800 MB.

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*

Name*

Legal First Name Legal Last Name

Gender*

Birthday*

Primary Diagnosis*

Did this VIP receive a VIP Membership ID # ?*

Child #4 VIP Membership ID #*

Acceptable Proof of Disability (You must upload one of the following):*

Please upload Proof of Disability (type chosen above)*

Max. file size: 800 MB.

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*

Name*

Legal First Name Legal Last Name

Gender*

Birthday*

Primary Diagnosis*

Did this VIP receive a VIP Membership ID # ?*

Child #5 VIP Membership ID #*

Acceptable Proof of Disability (You must upload one of the following):*

Please upload Proof of Disability (type chosen above)*

Max. file size: 800 MB.

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*

Name*

Legal First Name Legal Last Name

Gender*

Birthday*

Primary Diagnosis*

Did this VIP receive a VIP Membership ID # ?*

Child #6 VIP Membership ID #*

Acceptable Proof of Disability (You must upload one of the following):*

Please upload Proof of Disability (type chosen above)*

Max. file size: 800 MB.

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*

Name*

Legal First Name Legal Last Name

Gender*

Birthday*

Primary Diagnosis*

Did this VIP receive a VIP Membership ID # ?*

Child #7 VIP Membership ID #*

Acceptable Proof of Disability (You must upload one of the following):*

Please upload Proof of Disability (type chosen above)*

Max. file size: 800 MB.

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*

Name*

Legal First Name Legal Last Name

Gender*

Birthday*

Primary Diagnosis*

Did this VIP receive a VIP Membership ID # ?*

Child #8 VIP Membership ID #*

Acceptable Proof of Disability (You must upload one of the following):*

Please upload Proof of Disability (type chosen above)*

Max. file size: 800 MB.

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*

Name*

Legal First Name Legal Last Name

Gender*

Birthday*

Primary Diagnosis*

Did this VIP receive a VIP Membership ID # ?*

Child #9 VIP Membership ID #*

Acceptable Proof of Disability (You must upload one of the following):*

Please upload Proof of Disability (type chosen above)*

Max. file size: 800 MB.

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*

Name*

Legal First Name Legal Last Name

Gender*

Birthday*

Primary Diagnosis*

Did this VIP receive a VIP Membership ID # ?*

Child #10 VIP Membership ID #*

Acceptable Proof of Disability (You must upload one of the following):*

Please upload Proof of Disability (type chosen above)*

Max. file size: 800 MB.

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?*

Family Income Level:

Ethnicity 1

Ethnicity 2

Acknowledgement, Release, and Waiver*

I agree to the below:

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, Harvestime Apostolic Temple, 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 and Harvestime Apostolic Temple from any liability or claim that VIP Family may have against Nathaniel's Hope and Harvestime Apostolic Temple 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 Harvestime Apostolic Temple or its officers, directors, employees, agents, or otherwise. VIP Family also understands that Nathaniel's Hope and Harvestime Apostolic Temple 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 and Harvestime Apostolic Temple in writing; Nathaniel's Hope nor Harvestime Apostolic Temple 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 and Harvestime Apostolic Temple does not pre-screen Buddies as they are Volunteers for the Friendship Stroll and Nathaniel's Hope nor Harvestime Apostolic Temple 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 and Harvestime Apostolic Temple all right, title, and interest in any and all photographic images and video or audio recordings made by Nathaniel's Hope and Harvestime Apostolic Temple 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.

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VIP Birthday Club

Prayer Support

Fun Activities for Kids

Resources for Parents

VIP Families/Get a Break

Buddy/Be A Friend

Churches/Give a Break

Florida

Ohio

Current Volunteer Needs

Celebrating Kids with Special Needs, our VIPs

Celebrating Kids with Special Needs, our VIPs

VIP Birthday Club

Prayer Support

Fun Activities for Kids

Resources for Parents

VIP Families/Get a Break

Buddy/Be A Friend

Churches/Give a Break

Florida

Ohio

Current Volunteer Needs

MAKE ‘m SMILE Ohio VIP Registration

Ohio MAKE 'm SMILE VIP Registration

Parent 1 Information

Parent 2 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