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* indicates required fields |
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Adult Name: *
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Home Phone:
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Cell Phone:
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Work Phone:
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Email Address:
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Number of Adults Attending:
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Number of Children Attending:
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How many cars will you need parking spaces for?
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How did you hear about this Keep ‘m Smiling event?
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Which performance?
(you can choose only one)
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Wednesday (Dec. 3) Thursday (Dec. 4) |
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Does your child use a wheelchair/stroller?
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No Yes |
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If Yes, do you need to be seated in the wheelchair area of the theater OR do you want to transfer your child out of his/her wheelchair/stroller into a theater seat?
Transfer to Theater Seat
(Their chair or stroller will be placed in a nearby hallway.)
Wheelchair Area
(If you need to be in the wheelchair area, you will automatically be on a waiting list because there are so few seats there. If we are able to accommodate your request, there will need to be one adult with the child and your child will be seated in front of the adult. The rest of the party will be in general seating.) |
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REMINDERS
- Time: Doors open at 5:45 p.m. for wheelchairs, 6:00 for general. Arrive 30 minutes earlier than seating time for parking reasons.
- Parking: You must park at Orlando Lutheran Academy at 550 North Econlockhatchee Trail, Orlando, FL (across the street from the theater). Parking and shuttle specifics are to be determined and will be updated on our website.
- Seating: There is no assigned/reserved seating unless you are in the wheelchair area.
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| If your child is already enrolled in our VIP Birthday Club and you receive mailings from us, please scroll down to the bottom and click on Submit. If your child is not a part of our Birthday Club or you are not receiving mailings, please fill in the following information: |
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Child's First Name:
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Child's Last Name:
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Child’s Birthday (mm/dd/yy):
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Please explain your child’s special need(s):
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Child’s School (if applicable):
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Gender:
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Male Female |
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What special equipment does your child use, if any (walker, wheelchair, etc.)?
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What special talents or abilities does your child have?
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We celebrate our VIP Birthday Club members online. Please indicate your preference regarding the online portion of the VIP Birthday Club:
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Name on Web
First name only on Web
DON’T list name on Web
Picture on Web
DON’T put picture on Web |
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What is your relationship to the VIP?
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Home Address:
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City:
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State:
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Zip/Postal Code:
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Home Church (if any):
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Home Church City:
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Do you speak…
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Spanish? Sign Language? |
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| Optional Demographic Information: When applying for grants, we are asked for certain information. By responding to these optional questions, you will be helping us in garnering funds for Nathaniel’s Hope. |
| Family income level: |
<$20,000 $20,001-30,000 $30,001-40,000
$40,001-50,000 $50,001-60,000 >$60,001 |
| Race/Ethnicity: |
African-American/Black American Indian or Alaska Native
Asian Indian Caucasian/White Chinese Filipino
Guamanian or Chamorro Hispanic/Latino/Latina Japanese
Korean Native Hawaiian Pacific Islander
Samoan Vietnamese |
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Other, please specify |
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Release Form
In consideration of me, my family, and/or my minor child(ren), I agree to indemnify and hold harmless Nathaniel’s Hope from all cost, expense, liability arising out of my family, my child’s, or my own participation in this event. I do hereby waive all claims for damage or loss to me, my family, or my child’s person or property which may be caused by any act, or failure to act, by Nathaniel’s Hope, its officers, agents, or employees from me, my family, or my child’s loss, damage, or other liability from such event.
By my participation I grant Nathaniel’s Hope and any third party it may authorize, the right to photograph me and my family, and/or make recordings of my physical likeness and/or recordings of my voice for use in or in connection with exhibitions, video, magazines, newspapers, internet, or other publications or on television or radio.
By submitting this form, I agree with the release form information above.
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