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Our Team
ASSISTANCE
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What Makes Me Special
About Us
Our Team
ASSISTANCE
SUPPORT OUR MISSION
Apply Now
What Makes Me Special
Experience Application
Please complete the form below. This is the first step for a child to receive an Experience. Once we receive the completed form, our team of dedicated volunteers will respond as soon as possible.
REFERRER'S INFORMATION
Your Name
*
First Name
Last Name
Relationship to Child
*
Parent/Guardian
Medical Professional
Teacher
Family Friend
Other
Your Email
*
Your Phone
*
(###)
###
####
How did you hear about us?
*
CHILD'S INFORMATION
Please provide as much information as possible
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
MM
DD
YYYY
Parent/Guardian
*
First Name
Last Name
Parent/Guardian
First Name
Last Name
Parent/Guardian's Email
*
Parent/Guardian's Phone
*
(###)
###
####
Child's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Medical Condition
*
Please describe the child and why you are applying for them
*
Experience Applying For
*
Please provide a brief description of the Experience you had in mind for this child.
Thank you, your form has been submitted successfully!
