First Name

Last Name

Phone *

Email *

My Child's Diagnosis/Condition *

Child Date of Birth *

City

Referral Source

Reason for Sponsorship *

Household with more than one member with special needs / disabilities

Main caregiver has disability

Financially Challenged

Single parent with multiple children

Grandparents as main caregiver

Foster /Adoptee family

Service desert - Commute to closest intervention facility is over 90 minutes each way; On waitlist / not accepted for any SLT service for over 9 month

You will need to provide proof when asked

Notes for the team

By clicking SUBMIT, I understand and consent to the PenguinSmart Team releasing anonymized images, videos and stories of my family to share with sponsors as program updates.