Nominate A Family

Please fill out as much as you are able to or are comfortable with sharing, as it will help us in the selection process.

Special Needs Child Information
Name*
First Last
Age*
Please enter a number from 0 to 16.
Please note: due to limitations in providing therapy in on-the-go settings, our age limit is 16 years of age.
Diagnosis
Therapies Received (please include frequency)
Family Information
Name of Parent or Guardian*
First Last
Parent or Guardian Email*
- Yes, parent/guardian would like to receive updates from Enriching Escapes!
Parent or Guardian Phone
Family's Home City*
City State / Province / Region
Please explain why you believe this family deserves an Enriching Escape.*
Your Information
How did you hear about Enriching Escapes?*
Are you a parent/guardian nominating your own family?*
- Yes
- No
Your Relationship to Nominee*
- Extended Family (Grandmother, Grandfather, Aunt, Uncle, etc.)
- Therapist (PT, OT, SLP, ABA, etc.)
- Family Friend
- Other
If "Other", please specify
Your Name*
First Last
Your Email*
- Yes, I would like to receive updates from Enriching Escapes!
Your Phone
Disclaimer*
- By filling out the requested information and clicking submit, you are attesting that you are the parent/legal guardian of the child(ren), or that the child(ren)'s parent/legal guardian has authorized you to release and share information about the child(ren) with us. Please see our Privacy Policy for any concerns regarding the protection of personal information.

Special Needs Child Information