Sunshine on a Ranney Day Application
Sunshine on a Ranney Day is currently accepting applications for dream bedroom makeovers. Children aged 4-21 diagnosed with a long-term illness or disability are welcome to apply. To receive a makeover, the child's family must own their own home and have a plan for how their child will be cared for during the construction process.
Child's Name
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First Name
Last Name
Child's Age
*
Child's Gender
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Please Select
Male
Female
Child's Birthdate
*
Please select a month
January
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Child's Permanent Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the child live within a 40 mile radius of 30075?
*
Please Select
Yes
No
Has the child previously been nominated or applied for a Sunshine on a Ranney Day makeover?
*
Please Select
Yes
No
What is the child's illness or diagnosis? Please explain how they received the diagnosis (e.g., changes in behavior lead to a doctor's visit, etc.)
*
Is the child verbal?
*
Please Select
Yes, Verbal
No, Non-verbal
Is the child independently ambulatory?
*
Please Select
Yes, can walk independently
No, requires assistance via wheelchair or other mobile device.
Who referred you to Sunshine on a Ranney Day?
Please provide a brief description of how the child's diagnosis/illness affects their daily caregiving routine.
*
Does the child have sensory issues?
*
Please Select
Yes
No
If yes, please explain the sensory issues
Does the child have destructive tendencies, such as breaking items in the home, kicking holes in walls, etc?
*
Please Select
Yes
No
If yes, please explain the destructive tendencies.
If no, please write NO in box.
Does the child regularly attend therapy?
*
Please Select
Yes
No
If yes, what type of therapy? (Choose all that apply)
Physical Therapy
Occupational Therapy
Emotional Support Therapy
Speech-Language Therapy
Applied Behavioral Therapy (ABA)
Sensory Integration Therapy
Music Therapy
Hippotherapy (Therapeutic Horseback Riding)
Aquatic Therapy (Hydrotherapy)
Social Skills Therapy
Play Therapy
Feeding Therapy
Other
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Parent/Legal Guardian's Full Name (main point of contact for all communication)
*
First Name
Last Name
Parent/Legal Guardian's Email Address
*
example@example.com
Parent/Legal Guardian's Phone Number
*
Please enter a valid phone number.
Relationship to Child
*
Parent/Legal Guardian's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Parent/Legal Guardian
First Name
Last Name
Additional Parent/Legal Guardian's Email
example@example.com
Additional Parent/Legal Guardian Phone
Please enter a valid phone number.
Relationship to Child of Additional Contact
*
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Child's Information
Child's Primary Care Physician
*
First Name
Last Name
Child's Primary Care Physician's Email
*
example@example.com
Child's Primary Care Physician's Phone Number
*
Please enter a valid phone number.
If necessary, may we contact the child's Primary Care Physician for more information on how a makeover could better assist them?
*
Please Select
Yes
No
Child's Primary Therapist
First Name
Last Name
Child's Primary Therapist's Email
example@example.com
Child's Primary Therapist's Phone Number
Please enter a valid phone number.
Type of therapy the Primary Therapist performs
If necessary, may we contact the child's Primary Therapist for more information on how a makeover could better assist them?
Please Select
Yes
No
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Please choose up to two (2) options below where the child would benefit a makeover
*
Accessible Bathroom - Typically involves roll-in shower, widened doorway (when existing structure allows), grab bars, accessible vanity and a side transfer toilet.
Dream Bedroom - Involves decorating a bedroom for a child who needs a comfortable and upbeat place to hang out, recover and just be a kid.
In-Home Therapy Room - With guidance from the child's therapist(s), an existing finished room in the home will be converted into a therapy room where the child can thrive. Therapy equipment is limited to funding availability. *NOTE* In-Home Therapy rooms are intended to supplement out of the home therapy, not replace it.
Ramp - This would be an exterior ramp into the entrance of the child's home.
Please tell us all about the child's interests. What are the child's favorite characters, shows, or interests?
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Please upload a picture of the child
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Please upload a picture of the child with their family
*
Please explain how a bedroom makeover would benefit the child
*
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Home and Space
Please upload a picture of the space
*
Please upload a second picture of the space
*
Number of people living in the home.
*
How long do you plan on residing at the makeover address?
*
Does the parent/legal guardian own the home?
*
Please Select
Yes
No
Has the parent/legal guardian moved more than once in the past 3 years?
*
Please Select
Yes
No
Is the parent/legal guardian current on all mortgage payments and property taxes?
*
Please Select
Yes
No
Has anyone in the immediate family or residing in the home been convicted of a felony or misdemeanor, not including traffic violations?
*
Please Select
Yes
No
By initialing below, I acknowledge my understanding that Sunshine on a Ranney Day only works within the existing structure of the home in a finished, heated and cooled space; i.e., we do not provide additions to the current footprint of the home or convert unfinished garages or basements.
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Initial
By initialing below, I understand that Sunshine on a Ranney Day only replaces carpet with hard surface flooring for the need of a child whose care would benefit from hard surface flooring; e.g., confined to a wheelchair or exhibiting a skin sensitivity that is exacerbated by carpet
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Initial
By initialing below, I acknowledge my understanding that Sunshine on a Ranney Day DOES NOT complete kitchen remodels.
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Initial
By initialing below, I understand that Sunshine on a Ranney Day DOES NOT install pools or hot tubs for therapy purposes.
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Initial
By initialing below, I understand that Sunshine on a Ranney Day DOES NOT donate, raise money, pay bills, including mortgages, or purchase homes or vehicles.
*
Intital
I certify that the home currently does not have any known lead, asbestos or mold?
Initial
By initialing below, I acknowledge my understanding that Sunshine on a Ranney Day only completes bathroom renovations for a child over the age of 4 who requires assistance with bathing.
*
By initialing below, I understand that Sunshine on a Ranney Day only replaces carpet with hard surface flooring for the need of a child whose care would benefit from hard surface flooring; e.g., confined to a wheelchair or exhibiting a skin sensitivity that is exacerbated by carpet.
*
By initialing below, I acknowledge my understanding that Sunshine on a Ranney Day only installs wheelchair ramps on the exterior of the home.
*
By initialing below, I acknowledge my understanding that Sunshine on a Ranney Day DOES NOT complete kitchen remodels.
*
By initialing below, I understand that Sunshine on a Ranney Day DOES NOT install pools or hot tubs for therapy purposes.
*
By initialing below, I understand that Sunshine on a Ranney Day DOES NOT donate, raise money, pay bills, including mortgages, or purchase homes or vehicles.
*
I certify that the home currently does not have any known lead, asbestos or mold?
*
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I certify that the information provided in this application is true, accurate, and complete. I authorize Sunshine on a Ranney Day and its representatives to verify my statements and contact listed references. I consent to the release of relevant information without liability to Sunshine on a Ranney Day, its affiliates, or authorized representatives.By submitting this application, I waive and release Sunshine on a Ranney Day and its affiliates from any liability related to the release of such information, including negligence. Note: This application is reviewed without regard to race, color, religion, income, national origin, sex, disability, or marital status.
*
I certify that the information provided in this application is true, accurate, and complete. I authorize Sunshine on a Ranney Day and its representatives to verify my statements and contact listed references. I consent to the release of relevant information without liability to Sunshine on a Ranney Day, its affiliates, or authorized representatives. By submitting this application, I waive and release Sunshine on a Ranney Day and its affiliates from any liability related to the release of such information, including negligence. Note: This application is reviewed without regard to race, color, religion, income, national origin, sex, disability, or marital status.Initials
*
By typing my name below, I certify that the information provided in this application is true, accurate, and complete. I authorize Sunshine on a Ranney Day and its representatives to verify my statements and contact listed references. I consent to the release of relevant information without liability to Sunshine on a Ranney Day, its affiliates, or authorized representatives. By submitting this application, I waive and release Sunshine on a Ranney Day and its affiliates from any liability related to the release of such information, including negligence. Note: This application is reviewed without regard to race, color, religion, income, national origin, sex, disability, or marital status.
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