Nominate A Child

KIDSgala Application

* Indicates required questions
*Indicates required field
Child's Name *
Date of Birth *
Parents' Name(s) *
Email *
Email of Nominated Child's Parent/Guardian *
Phone # *
Address *
City *
State *
Zip/Postal Code *
Description of Illness, Disability or Accident *
Physician Name/Address/Contact Number *
Date Last Seen by a Physician *
Name of Immediate Family Member or Social Worker Submitting Application *
Relation to Child Applicant *
Date *
How did you hear about us? *

Founded in loving memory of Nicole Marie Burton...

A foundation created in the memory of Nicole Marie Burton, to provide a gifted celebration to children who have or are battling a life altering event. KIDSgala is dedicated to hosting events that will individually celebrate each child’s life achievements...

Read Nicole's Story Learn About Our Organization