A little room, for a lot of caring!

Nominate A Child or Family for a
Nathan's Playroom Package

Please fill out this form and provide as much information as possible for the Child/Family you are nominating for a Nathan's Playroom package. Each nomination will be reviewed on an individual case by case basis. Nathan's Playroom packages are for children up to 14 years of age. Please send any nomination questions or inquiries to Nominations@NathansPlayroom.org.

Name - Child 1 (First & Last): *
Name - Child 2 (First & Last):
Name - Child 3 (First & Last):
Family Name:
Street Address - Line 1: *
Street Address - Line 2:
City: *
State / Province: *
Zip / Postal Code: *
Country: *
Age - Child 1:
Age - Child 2:
Age - Child 3:
Reason for request: *
Other Notes:
Your Name (First & Last): *
Your contact email: *
Your contact phone number:
Do you wish to remain anonymous?: