Program Application/Information/Release

OFFICE USE ONLY

Date form received: ______

Date package mailed: ______

Assembled by: ______

Postage:

Added to CC:______

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 ___ Cancer Fears Me ___ Cool Kids Connection ___ Cool Kids Learning Center ___ Family Outings In Baltimore

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______

Email address______Father’s/Legal Guardian name______

Address if different from above______

______

Employer______

Home Phone______Cell Phone______

Email address______

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.

2 Parent/Guardian Signature______Date______

Parent/Guardian Signature______Date______

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______Color______

Book/Magazine______Subject in school______

Movie______TV Show/Channel ______

Sport to play/watch______Band/Artist______

Restaurant______Board Game______

Store ______Clothing Size______

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______

Email______

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

____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______Email______

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______email______

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 21204 Office: 410-560-1770 Fax: 410-560-1775 www.coolkidscampaign.org

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.

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______

Email______

If child has two parents or legal guardians, both must sign below:

Parent/Guardian______Date______

Witness______Date______