Fill out this form to nominate a child for the Supercross Dream Room Makeover.
Name of Child Being Nominated *
Your answer
Age
Age of child being nominated
Your answer
Contact Name (Parent of Child) *
Parent contact for child being nominated
Your answer
Contact Phone Number *
Phone number for nominated child's parent
Your answer
Contact Email
Email address for parent
Your answer
City *
The city that the family lives in
Your answer
At which hospital is the child treated? *
For example, Seattle Children's
Your answer
Name and number of Child Life Specialist *
Typically a chronically ill child has a person from the hospital who is familiar with their situations, likes and dislikes.
Your answer
Please describe why you think the child should be a recipient of the Supercross Dream Room Makeover? *
Please include any relevant issues about the child's illness, recovery or injury.
Your answer
Is the child a fan of Supercross? *
If yes, please describe their involvement in the sport, e.g., watching it on TV, going to the Seattle race, participating in MX.
Your answer
Your name
If different from the contact name.
Your answer
Your relationship to the child *
For example, father/mother, caregiver, sibling, friend of family
Your answer
Submit
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