Family inclusion interest form

Tell us what your child wants to experience—and what is standing in the way.

Share the outing, activity, trip, recreation, or family moment that matters. This form helps us understand participation barriers and possible mission fit. It is not an application for general medical equipment and does not replace Medicaid, insurance, clinicians, or established equipment programs.

Family interest form is open

Tell us about the experience your child wants to join. Beyond the Pavement is gathering inclusion needs while programs and partnerships are being developed. This is an interest form, not a promise of assistance or funding.

Before you submit

Keep the first message simple.

Tell us about the experience your child wants to join and the barrier standing in the way. Do not send full medical records, Social Security numbers, insurance IDs, payment information, genetic reports, or other highly sensitive documents through this form.

What to includeParent or guardian contact information, child’s first name or initials, the experience or opportunity, the participation barrier, helpful accessibility or planning details, and any timing or location information.

Parent / guardian name

Child’s first name or initials

Experience category

What barrier is making participation difficult right now?

What experience or opportunity would your child like to join, and what could help make it possible?

Location, timing, or planning details

Partners or community resources already contacted

Date or time-sensitive circumstance

I understand this is an inclusion interest form, not a request for medical care or general equipment funding, and I will not submit full medical records, Social Security numbers, insurance identification numbers, payment information, or other highly sensitive records here.