Date:

Digital Signature:

I have permission to nominate the child from their parent/ guardian (Yes/ No)

I confirm that the information provided is accurate to the best of my knowledge (Yes/ No)

Organization (if applicable):

Nominator email:

Nominator phone #:

Relationship to child:

Name of nominator:

Nominator Information

Any special needs or considerations (sensory sensitivities, mobility, etc.

Child's Interests, Hobbies, Favorite Colors/ Characters/ Sports Teams

Please share the child's story and how a new space could positively impact them

Reason for Nomination

Caregiver email:

Caregiver phone #:

Address:

Name of
child: