Quality of Life New Applicants - Carrie Tingley Hospital Foundation

CTHF Quality of Life Programs - New Applicant Form

The information you share is provided to the Quality of Life Coordinator in order to best assist your child. If you ever have a concern, or your child's health conditions change, please let the coordinator know.

Child's Name(Required)

Nickname

Date of Birth

Age(Required)

Please enter a number from 0 to 100.

Gender

Male

Female

Prefer not to provide

Address(Required)

City(Required)

State(Required)

ZIP(Required)

Parent/Guardian's Name(s)(Required)

Phone(Required)

Email(Required)

What is your family's annual income?(Required)

For grant applications

Number of household members(Required)

For grant applications

What is your ethnicity?

MEDICAL HISTORY

Diagnosis(Required)

Please explain what your current diagnosis is or what you know about it briefly

Past Medical History(Required)

Please explain any pertinent history that could affect physical activity

Past Surgical History(Required)

Please explain any pertinent history that could affect physical activity

Medications(Required)

What and how often

Do you have any Range of Motion (ROM) limitations?(Required)

Yes

If YES, please explain

Can you walk independently?(Required)

Yes

If NO, what type of support?

Do you use any adaptive devices or adaptive equipment? If so, what is used?

Wheelchair Use(Required)

Full-time

Part-time

None

Type

Manual

Power

Can you transfer independently?(Required)

Yes

If NO, how much assitance do you need?(Required)

100% (Cannot do any work)

75%

50%

25% (Can do most work)

Have you ever been a Carrie Tingley Hospital Patient?

Yes

Past

Present

Have you ever participated in adaptive sports programs before? If so, which sports?

Do you have any precautions regarding exercise given from a medical provider? If so, please provide:

Do you have any food allergies?(Required)

Snacks provided after activities

Yes

If yes, please provide list of food allergies.

Shirt Size

Adult

Youth

XL and XXL = adult only

PHOTOGRAPH CONSENT FORM

I grant permission to Carrie Tingley Hospital Foundation, a 501c3 non-profit, to use photographs/videos taken of me on the date listed below for use in publications such as brochures, newsletters, social media, television, newspaper, and magazine publications, to use the photographs on display boards, and to use such photographs in electronic versions of the same publications or on websites or other electronic form or media. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation that arises from or related to the use of the photograph. I hereby agree to release, defend, and hold harmless Carrie Tingley Hospital Foundation, its agents or employees, including any firm publishing and/or distributing the finished product in whole or part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution. I understand this PHOTO/MEDIA Release may also be used by Carrie Tingley Hospital Foundation third party partners. Consent for Minor: (if under 18 years of age) I am the parent or legal guardian of the minor named above and have the legal authority to execute the above release. I approve the foregoing and waive any rights in the premises.

Parent Consent

Yes, I provide my consent for my child's photo per the terms provided

No, I do not provide my consent for my child's photo to be used by Carrie for any purpose

Child Name(s)(Required)

I understand that they will not use my child’s name or my name unless I give express permission for them to do so(Required)

Yes, you may use my first name (Parent/Guardian)

Yes, you may use my child/children’s first name(s)

No, I prefer you do not use any of our names

Parent Signature(Required)

Date(Required)

Parent/Guardian Printed Name(Required)

Phone(Required)

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT WITH PARENTAL CONSENT (“AGREEMENT”)

IN CONSIDERATION of being permitted to participate in any way in any event (“Activity”) at any time during the current calendar year I, for myself, my personal representatives, assigns, heirs, and next of kin: 1. ACKNOWLEDGE, agree,and represent that I understand the nature of the Activity and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the conditions to be unsafe, I will immediately discontinue further participation in the Activity. 2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH (“Risks”); (b) these Risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activity, the conditions in which the Activity takes place, or THE NEGLIGENCE OF THE “RELEASEES” NAMED BELOW; (c) there may be OTHER RISKS or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation, or that of the minor, in the Activity. 3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel, sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which may be incurred as the result of such claim. I ACKNOWLEDGE THAT I AM AGE 18 OR OLDER, HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT

Parent/Guardian Printed Name(Required)

Signature(Required)