Nominate A Child Do you know a child who deserves to go to Disney World? Please review our Child Criteria and then enter the information below. Tell Us About YouWho are you?*AgencyParent/GuardianWhat is the name of your agency? Is your agency part of Clearwater?*Please Select OneYesNoWhich Coalition does the child live in?Please Select OneMiawpukekMembertouPotlotekWe'koqma'qPaqtnkekPictou LandingSipekne'katikYour first and last name?* First Last Your email address*This is how we will typically communicate with you. Your phone number*In case we can't reach you by email. How do you know the child?* HiddenOn a scale of 1-5, rate how well you know this child and their families situation.*1 being not very well and 5 being very well. 1 2 3 4 5 On a scale of 1-5, rate how well you know this child and their families situation.*1 being not very well and 5 being very well. 12345Tell Us About The ChildPlease be as detailed as possible on this form. This is the information we use when selecting the children for the program. Please be truthful, if we determine that the information on this form is untrue, the child could be disqualified from the program. Child's Given Name* First Last Child's Preferred Name* Child's Date of BirthPlease note the child must be between the ages of 8 and 14 on April 1, 2024. If they are not then they will NOT qualify for this program. What is the child's sex?* How does the child identify?* What is the child's pronouns?* What is the child's culture/ethnicity?* What area does the child live in?*This helps us ensure that we are selecting children from a variety of areas across the 4 provinces. Tri-County, Nova ScotiaSouth Shore, Nova ScotiaHalifax, Nova ScotiaCape BretonPrince Edward IslandNewfoundlandSt. John, New BrunswickFredericton, New BrunswickOtherOther: Please specify the area the child lives in. Child's Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code What school does the child attend?* Do the parents/guardians have the child's long form birth certificate?*This is REQUIRED! The long form birth certificate lists the parents names on it. It can take up to 3 months to receive, if you do not have it, you need to order it right away. YesNoPlease upload a photo of the long form birth certificate.Max. file size: 293 MB.Does the child have a family doctor or nurse practitioner?*If yes, please book an appointment with your family doctor or nurse practitioner between November 1 and 20 to have a medical form filled out. If no, please note that you will need to find a walk in clinic willing to complete the form. YesNoDoes the child have any mobility challenges?*YesNoYes - please describe the nature of these mobility challenges and how we can best meet the needs of the child.Does the child have any diagnosis?*YesNoYes - Please provide details of the diagnosis.Does the child take any medication?*YesNoYes - Please provide details on the medication(s).Does the child have any behaviour problems?*YesNoYes - please describe the behaviour problems.Does the child require the support of a TA/EPA throughout their school day to be safe and successful.*YesNoYes - Please describe how the child is supported by a TA/EPA.Please list any places the child has visited or activities the child has participated in.*This could be visiting a place outside their hometown or activities such as hockey, gymnastics, ect.. Please use the + sign on the right hand side to add lines. Has the child ever been on a plane before?*YesNoYes - Please describe the circumstances of the plane travel.Has the child ever left their home province before?*YesNoYes - Please describe the circumstances of leaving their home province.Has the child ever been to a theme park before?*YesNoYes - Please list the theme parks and dates attended.Does the child's family have any vacation trips planned with this child within the next 12 months?*YesNoYes - Please describe the planned vacation trip.HiddenOn a scale of 1-5, how does the child react to lack of sleep?1 being does not react well and 5 being very well. 1 2 3 4 5 How does the child react to a lack of sleep?*GoodSomewhat goodNot goodHow does the child react to change?*GoodSomewhat goodNot goodHiddenOn a scale of 1-5, how does the child react to change?1 being does not react well and 5 being they handle change with ease. 1 2 3 4 5 How does the child react to new experiences?*GoodSomewhat goodNot goodHiddenOn a scale of 1-5, how does the child react to new experiences?1 being does not react well and 5 being very well. 1 2 3 4 5 How does the child handle large groups of people?*GoodSomewhat goodNot goodHiddenOn a scale of 1-5, how does the child handle large groups of people?1 being does not handle well and 5 being handles very well. 1 2 3 4 5 How does the child handle being with people they don't know??*GoodSomewhat goodNot goodHiddenOn a scale of 1-5, how does the child handle being with people they don't know?1 being does not handle well and 5 being handles very well. 1 2 3 4 5 Can the child walk 20,000 steps in one day with limited breaks?*YesNoNo - Please describe how we can meet the needs of the child throughout the day.This could be wheelchair, more breaks, etc.Has the child ever been away from their parents/guardians overnight before?YesNoCan they handle being away for 3 days?YesNoDoes the child have any concerns with bed wetting?YesNoHas the child had a sibling attend the program in the past?*YesNoYes - Please provide the first and last name of the sibling. Does the child have any siblings that should be considered for the program?*If yes, please complete a separate nomination form for each sibling. YesNoYes - please list the names of the siblings. Why do you want to nominate this child?*Tell us the child's story, please be as detailed as possible. We use this information to help select the children for the program. Consent* I have read and understand the Child Criteria.*Consent* I agree that this child is an appropriate fit for this program.*Consent* I agree that the information provided in this form is true to the best of my knowledge.*Nominating Person's Signature*CAPTCHAEmailThis field is for validation purposes and should be left unchanged.