Brighter Journeys' Nominate a Family for Hersheypark Tickets

Brighter Journeys' Nominate a Family for Hersheypark Tickets
Thanks to the generosity of Penn Hospital and the unit who cared for our co-founder, Lisa Urbanski, we are honored to give away four Hersheypark tickets to one deserving family that has a child with special needs.

Families may nominate themselves or be nominated by someone else. All eligible submissions will be entered in a random drawing. Winner will be selected on May 29th.

One entry per family. Poof of disability required. Family must reside in the counties Brighter Journeys services. Please visit our website for list of counties. brighterjourneys.net
Are you nominating your own family or another family?
Relationship to family you are nominating
Full Name of person filling out this form

First NameLast Name
Contact Number of person filling out this form
Please enter a valid phone number.Format: (000) 000-0000.
Email Address of person filling out this form
example@example.com
Parent/Guardian Name

First NameLast Name
Child's First Name
Child's Age
County child lives in
Example: Luzerne
Child's Diagnosis
Please attach documentation supplied from the Individual's doctor pertaining to diagnosis

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Please attach documentation supplied from the Individual's doctor pertaining to diagnosis. If you are nominating a family and do not have this documentation please specify in the additional information below.

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Tell us a little about this child/family and why a fun day at Hersheypark would mean so much.
Additional Information
Should be Empty: