Make Magic Happen for a family with special needs!
Part 1: Applicant/Family Information
Applicant Information
Applicant Name * Applicant Age
Parent/Guardian Information
Parent/Guardian Name *  
 
Address *
City * State
ZipCode *  
Phone * Email *
 
 
Part 2: Family Questions
 
Please answer the following questions yes or no
Has your child been to Walt Disney World or Disneyland before?
(If yes, your child does not meet the application requirements. Please do not apply.) 		         

The recipient and a family member will be required to attend the Recognition Ceremony and appear at the Section on Pediatrics booth in the Exhibit Hall at the Section on Pediatrics Annual Conference (SoPAC), November 8-10, 2013. Will you be able to attend these events? (If no, please do not apply)

         
A family member is encouraged to participate in a Roundtable Discussion during SoPAC. Are you willing to participate in a Roundtable Discussion?          
A family member will receive a complimentary SoPAC conference registration. Are you interested in attending any of the SoPAC conference educational sessions?          
Your family is encouraged to participate in a Family Fun Run (wheelchairs included), if one is held. Are you and your family interested in participating in a Fun Run?          
Please answer the following questions in the number of words specified
Please tell us about your child, your family and why you think you should be chosen for this trip. (Please limit answer to 100 words.)
What effect/role has pediatric physical therapy played in your lives? (Please limit answer to 25 words.)
How will you use this experience when you get home to help promote pediatric physical therapy? (Please limit answer to 25 words.)
What physical fitness activities do you and your family like to do and/or what barriers do you have to getting your entire family involved in physical fitness activities? (Please limit answer to 25 words.)
Do you have any suggestions on how the Section on Pediatrics and/or your physical therapist could help your family participate in fitness activities? (Please limit answer to 25 words.)
 
Part 3: Referring Physical Therapist's Contact Information
Recommending/Treating Physical Therapist (must be Section on Pediatrics member)
Name * APTA Member#
Address *
City * State
ZipCode *  
 
Phone * Email *
Applicant's diagnosis or impairment according to IDEA:
Part 4: Physical Therapist Questions
Please answer the following questions in the number of words specified
Can you meet the requirements of attending SoPAC, the Recognition Ceremony, and appearing at the Section's booth?          
Can you meet the requirement of reporting back to the Section on Pediatrics regarding any follow-up activities that you and this family will engage in to promote the Section on Pediatrics and/or physical fitness?          
Please tell us about the child that you referred for this trip, why you think that this family should be chosen for this trip, and how you think this trip would help to maximize your referred child’s potential and quality of life. (Please limit answer to 100 words.)
How will you support this family at Disneyland/SoPAC if they are selected (eg, at the booth, races, etc)? (Please limit answer to 50 words.)
How will you use this experience when you get home to help promote pediatric physical therapy? (Please limit answer to 50 words.)
What have you done to help promote physical fitness for this family? (Please limit answer to 50 words.)
What would you do after this trip to help the family incorporate physical fitness activities into their lives? (Please limit answer to 50 words.)
 
 
 
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