4. Application

Application for an "FIA Disney Memory Vacation"

* Indicates required field

Name of person making nomination *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Relationship to child you are nominating *

Name of child being nominated *

First

Last

Age of child being nominated *

Does the child live in New York? *

Does the child you are nominating have a diagnosis of Autism Spectrum Disorder? *

yes no I don't know

Does the family of the child being nominated need the financial assistance of Families In Arms, Inc., in order to take a trip to Disney World? *

yes no I don't know

Please tell us why you chose this child and family to nominate for an "FIA Disney Memory Vacation." *

Submit

"The more you like yourself, the less you are like anyone else, which makes you unique." - Walt Disney