"A Day At The Races Application "

1.    Child's Name: _________________________________________________________

2.    Age: _________________________________________________________________

3.    Disability: _____________________________________________________________

4.    Where Do You Live: _____________________________________________________

5.    Special Needs At Race: __________________________________________________

6.    Who Will travel with youngster, there must be atleast one caregiver?

       ______________________________________________________________________

7.    Do you know if there is a track near you?  YES        NO

8.    Name of Track: _________________________________________________________

9.    How far are you able to travel: ____________________________________________

10.  Will You need financial assistance to get there?  YES        NO

11.  Is there anything you think is pertinent or may help us put this together and make it happen:

       ______________________________________________________________________

       ______________________________________________________________________

Thank You,
 

DYA Inc.