ARK Kid Nomination Form - Accessibility Renovations for Kids

Name of Nominee *

First

Last

Age of Nominee

Selected Value: 1

Multiple Choice

Name of Parent/Guardian *

First

Last

Relationship to Nominee *

Phone Number *

Email *

Name of Additional Parent or Guardian

First

Last

Relationship to Nominee

Phone Number

Nominee Home Address *

Do the parents/guardians own the house? *

In what year was the house built?

What is the family's Annual Household Income? (Approximate) *

What Medical Condition or Disability is the nominee coping with? What are their physical limitations? *

Which ARK Home Accessibility Renovations would help the nominee? *

Are there any constraints on the timing and completion of the renovation?

Your Name *

First

Last

Relationship to the Nominee *

Do you have a professional relationship with the nominee? What kind? (Occupational Therapist, Doctor etc.)

Phone Number *

Email *

Anything else you would like us to know?

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