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Enroll a VIP into Hall of Hope

It would be our honor to remember your loved one with you. Please fill out the following form to add your VIP child to our Hall of Hope. If you would like to have your child’s picture posted in the online portion of our Hall of Hope and you have not already sent it to us, please click here to email the picture.

Adult's First Name*:
Adult's Last Name*:
Child's First Name*:
Child's Last Name*:
Zip/Postal Code:
Home Phone:
Cell Phone:
Work Phone:
How did you hear about Nathaniel's Hope?
Child's Born Date (mm/dd/yy)*:
Child's Going Home Date (mm/dd/yy)*:
Please explain your child's special needs:
Child's Gender:  Male Female
Child's Special Talents/Abilities:
Would you like for your child's information to be included in the online portion of the Hall of Hope?* (This is not required to be a member of the Hall of Hope)*  Yes No
Please indicate your preference regarding the online portion of the Hall of Hope:
Image Upload (JPG, GIF, PNG):

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