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Become a VIP Birthday Club Member

Please fill out the following form to become a VIP Birthday Club Member!

If you prefer, you can mail a picture to Nathaniel’s Hope, 2300 Jetport Drive, Orlando, FL 32809-7800. Please include a note to tell us your child’s name, birth date, that this is for the VIP Birthday Club, and whether or not you would like the picture back. If we can keep the picture, we’ll add it to the collection of pictures posted in our office!

Adult's First Name
*required

Adult's Last Name
*required

Address

City

State

Zip/Postal Code

Country

Home Phone

Cell Phone

Work Phone

Email
*required

How did you hear about Nathaniel's Hope?

Please explain your child's special needs

Child's special talents/abilities

Child's First Name
*required

Child's Last Name
*required

Child's Birthday
*required

Child's School

Child's Gender
 Male Female

Would you like for your child's information to be included in the online portion of the VIP Birthday Club?* (This is not required to be a member of the VIP Birthday Club)*
 Yes No

Please indicate your preferences regarding the online portion of the VIP Birthday Club:


If you wish to include an image online, please select an image:

Please only upload an image that is 1 MB (1048576 bytes) or smaller.

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