New VIP Reservation

Please fill out the registration form below and click "submit" to make a reservation for your VIP at our next Buddy Break! We will call you to confirm your reservation the week of Buddy Break.

If this is your first time coming to a Buddy Break you will need to fill out the registration form below and attend a mandatory orientation at 11:00 am during Buddy Break. Please click here to download required paperwork for Buddy Break orientation.

Parent/Caregiver Name:

Child's Name:

Birthday:

Please explain your child's special need:

Child's school (if any): Grade:

Home Address: Apt. #:

City State Zip

Home Phone: Cell Phone:

Work Phone: E-mail:

What is the best time to reach you?

Home church (if any):

Church Address/City:

Names and ages of other children and will they be attending?

How did you hear about Buddy Break?

Have you been to a Buddy Break before? If so, at what location?

Is there anything else you'd like to share?

Buddy Break Date:

Orientation Date:

For information on other Buddy Breaks in the area, please visit Nathaniel's Hope.