Part 1: To be completed by Parent/Guardian. Please Print Clearly. Home Address. City ST ZIP. Mother s/legal Guardian name

Transcription

1 Cool Kids Campaign Program Application/ Information/Release The Cool Kids Campaign Foundation provides programs to children living with cancer. The mission of the Cool Kids Campaign is to provide kids with cancer a higher quality of life for themselves and their families while facing the challenges of cancer. Interested in: Cool Kids Care Package Cool Kids Connection Family Outings In Baltimore Cancer Fears Me Cool Kids Learning Center Part 1: To be completed by Parent/Guardian. Please Print Clearly Referred by Child s Name Date of Birth Age Gender (M/F) Home Address City ST ZIP Mother s/legal Guardian name Address if different from above Employer Home Phone Cell Phone address 1

2 Preferred method of communication: please choose one - /home phone/cell phone Father s/legal Guardian name Address if different from above Employer Home Phone Cell Phone address Preferred method of communication: please choose one - /home phone/cell phone Emergency Contact Information: Name: Relationship 1 st Number to call 2 nd Number to call Names and ages of other children living at home: 1) Name DOB Relationship 2) Name DOB Relationship 3) Name DOB Relationship 4) Name DOB Relationship 5) Name DOB Relationship Hospital where child is being treated Type of Cancer Date of Diagnosis Additional Information/Considerations: ( wheelchair, oxygen, etc use back of page if necessary) I understand and recognize that participation in any Cool Kids Campaign Foundation Programs is contingent upon approval by the Cool Kids Campaign Foundation as well as compliance with all conditions, qualifications and restrictions designated by the Cool Kids Campaign Foundation. Parent/Guardian Signature Date Parent/Guardian Signature Date 2

3 Part 2 To be completed by the patient or the parent/guardian for the patient. Please Print Clearly All about me: Name I preferred to be called Favorite: Activity TV Show Movie Type of Movie Sport to play Sport to watch Music Store Books Subject in school Vacation Food Restaurant Games If I could spend my time doing anything it would be Part 3 Cool Kids Learning Center Skip this section if you are not applying for Learning Center Programs. Please Print Clearly. Child s current grade Current School Address of School City ST Zip School Contact Phone 3

4 Part 3 Continued We are interested in the following Cool Kids Learning Center Programs: Individualized Tutoring Specifically in the area(s) of: Reading, Written Language, Math, Science, Social Studies, Foreign Language, Music, Art Group Tutoring Mommy and Me (preschool only) Social Activities/Outings in Baltimore School Advocacy Please describe in detail the needs of your child based on the services you are requesting. You may use the back of the page if needed. What days/times would best fit with your current schedule to attend the Learning Center program: Is there anything we should know to specifically help serve your child? Part 4 Medical Assessment to be completed by Physician. Please Print Clearly Name of Physician Hospital Phone 4

5 Part 4 Continued Diagnosis of Child Date of Diagnosis Is this child currently undergoing treatment? If not, last date of treatment: How often is this child seen by the hospital staff? Current type of treatment I believe there is no medical contraindication for this child to participate in the following Cool Kids Campaign programs or Cool Kids Campaign Learning Center. Physician s Signature Date Part 5 To be completed by Social Worker, Child Life Specialist or Registered Nurse. Please Print Clearly Name of Healthcare Worker Position Phone Programs recommended for this patient: Cool Kids Care Package Cool Kids Learning Center Social Activities Please tell us anything that will help us provide the best services to this child/family Please complete all sections of this form and return to: Cool Kids Campaign Foundation 8422 Bellona Lane, Suite 102 Towson, MD Office: Fax:

6 Liability Release and Authorization Disclosure (Page 1) As a requirement for participation in any Cool Kids Campaign Foundation Inc., program or service the parent(s) or legal guardian(s) must sign this liability release and authorization disclosure. Liability Release: The undersigned both individually, jointly and on behalf of the child who is eligible to participate in Cool Kids Campaign Foundation, Inc. programs understand that involvement in Cool Kids Campaign Foundation, Inc. programs may involve risk of injury or harm to the participant and that all risk is fully assumed by the undersigned. The undersigned both individually, jointly and on behalf of the child who is eligible to participate in Cool Kids Campaign Foundation, Inc. programs does hereby agree to release, forever discharge and hold the Cool Kids Campaign Foundation, Inc., their directors, officers, employees, agents, volunteers, successors and assigns harmless from and against any and all actions, causes of actions, liability, claims and demands for, any damages and claims of any kind whatsoever, whether known or unknown, in connection with or arising from any incident(s) or occurrence(s) during the child s participation or consideration of participation in Cool Kids Campaign Foundation, Inc. programs. Authorization to Disclose and Obtain Medical Information: The parent(s) or legal guardian(s) give Cool Kids Campaign Foundation, Inc. authorization to obtain all medical information which Cool Kids Campaign Foundation, Inc. may feel is necessary for the consideration or participation in Cool Kids Campaign Foundation, Inc. programs. The parent(s) or legal guardian(s) authorize all of the child s physicians and medical care providers to provide Cool Kids Campaign Foundation, Inc. with all the medical information regarding the child that is applicable to participate in Cool Kids Campaign Foundation, Inc. programs. Authorization for Disclosure to Third Parties: The parent(s) or legal guardian(s) understand and agree that Cool Kids Campaign Foundation, Inc. may disclose their child s identifying information to a third party in order for the third party to provide notices to the parent(s) or legal guardian(s) such as when an event is cancelled. Authorization regarding publicity: It is understood and agreed that participation in Cool Kids Campaign Foundation, Inc. may result in publicity that in order for Cool Kids Campaign Foundation, Inc. to continue its services, it is helpful to be able to portray children and families using programs in a positive way in brochures, newsletters, websites, and other promotional materials. The undersigned both individually, jointly and on behalf of the child who is eligible to participate in Cool Kids Campaign Foundation, Inc. authorize Cool Kids Campaign Foundation, Inc. to use the name and image of their child for publicity and promotional purposes. 6

7 Liability Release and Authorization Disclosure (Page 2) I grant I deny -- permission for Cool Kids Campaign Foundation, Inc. to use my child s name and image in Cool Kids Campaign Foundation promotional materials. This Liability Release and Authorization Disclosure contains the entire agreement between the parent(s) or legal guardian(s) and Cool Kids Campaign Foundation, Inc. and that the terms hereof are contractual and not a mere recital. By signing below, the parent(s) or legal guardian(s) of the child acknowledge they have read, understand and consent to the terms set forth herein. Child s Name Date of Birth Diagnosis Home Address City ST Zip Phone Cell If child has two parents or legal guardians, both must sign below: Parent/Guardian Date Parent/Guardian Date Witness Date 7