Know a special needs family that could use a vacation? 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 InformationName* 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 InformationName of Parent or Guardian* First Last Parent or Guardian Email* Yes, parent/guardian would like to receive updates from Enriching Escapes! Parent or Guardian PhoneFamily's Home City* City State / Province / Region Please explain why you believe this family deserves an Enriching Escape.*Your InformationHow 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 PhoneDisclaimer* 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.