This application is the first step in the reservation process. Current IEP and/or medical documentation of a life-threatening illness is required and provides a baseline for determining your eligibility.  

Please fill out the application below as thoroughly as possible to help us determine your eligibility. Once determined and space is available, we will be in touch to schedule your stay. If you are a single parent you are welcome to attend alone, bring a friend who has a child with special needs or a life threatening illness, or bring a significant other who lives in your home and assists in caring for your child.

Name *
Name
Phone *
Phone
Address *
Address
My child has *
Does your child live with you at home 7 days/week? *
If applicable, please describe the level of care you provide for your child in this area (the more detail you provide, the easier it will be to process your application)
Hospitalization
I will provide a copy of my child's IEP (504 or IFSP if applicable) or medical documentation of a life threatening disease in the following format *

If you are not sent to the thank you page after submitting this form please check that all the required fields are filled in. Do you have questions or need more information? Call us at 770-693-1462  or email at : info@restoreplace.org.