Gold Together Day at Valleyfair
The American Cancer Society has partnered with Valleyfair to host the first annual Gold Together Day for Childhood Cancer on Friday, August 23, 2024. If your family has been directly impacted by childhood cancer, we want to give you the opportunity to be our guest at this event. Simply complete this form and share how childhood cancer has had an impact on you or your loved one. Selected applicants will receive Valleyfair park admission, waterpark admission, parking, and lunch for everyone in your party. You will be notified if your application has been selected. If you have any questions, please submit them with your application and a member of the Gold Together team will contact you.
Contact Information:
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please share a bit about how childhood cancer has impacted you/your family.
What is the first name of the child in your life that battled cancer?
Name
Tell us a little about them. (Thought starters: Diagnosis, age at diagnosis or current age, what activities do they enjoy)
Would you be able to join us at Valleyfair on Friday, August 23, 2024?
Yes
No
Maybe
How many tickets are you requesting for Valleyfair on August 23, 2024 for your immediate family?
2
3
4
5
6
0 (We're not able to attend, but please honor our cancer warrior at the event)
Please list the names of the people that would join you at Valleyfair. Include the ages of any children and requested t-shirt sizes for all attendees (youth and unisex sizes available)
Please provide any dietary restrictions for any member of your family that would attend:
Does anyone in your group have mobility issues?
Please list mobility issues
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Photo
We would like to honor kids that have battled cancer at the event.
Can we feature your child as one of the children impacted by childhood cancer?
Yes
No
Maybe
Please submit a photo you would like us to feature:
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By sharing your child's story, you may inspire others to get involved in the fight against childhood cancer. Do we have your permission to feature your story on American Cancer Society of Minnesota social media?
Yes
No
Maybe
Do you have any questions? A member of the Gold Together team will contact you.
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By checking the box below, you agree to the following Image & Story Release Form:*I hereby irrevocably grant in perpetuity to the American Cancer Society, Inc., its legal representatives or assigns, affiliates (including, but not limited to, the American Cancer Society Cancer Action Network, Inc.) and those acting under its permission and upon its authority, or those for whom American Cancer Society Inc. is acting, the absolute right and permission to copyright, use, re-use, publish, and republish, and to license the right to use, re-use, publish and republish the following, in any medium or form of distribution without restriction as to changes or transformations in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for any purposes whatsoever, including, without limitation, illustration, art, promotion, advertising or trade: (a) photographic portraits or pictures of me or in which I may be included intact or in part, composite or distorted in character or form; (b) my likeness and/or voice on film or videotape, to edit or change or alter such recording(s) at its sole discretion in which I may be included in whole or in part, or composite or distorted in character or form, and (c) my testimonial (written) and edit such testimonial in its sole discretion. It is my understanding that I will receive no compensation for my likeness or testimonial. I hereby waive any right that I may have to inspect and/or approve the finished product or the advertising copy or printed matter that may be used in connection with my likeness or testimonial or the use to which it may be applied. I agree that I have no rights to the photographs, reproductions, negatives, videos or films, and all rights to such materials belong to American Cancer Society, Inc. I hereby release, discharge and agree to save harmless American Cancer Society Inc. and its employees or agents, affiliates, legal representatives or assigns and all persons acting under its permission or upon its authority or for whom it is acting, from any liability by virtue of any publication of my likeness or testimonial, including, without limitation, claims for libel or invasion of privacy, as well as any liability arising by virtue of any blurring distortion, alteration, optical illusion of use in composite form, whether intentional or otherwise, that may occur or be produced in the making of such picture or recording(s) or in any processing tending towards the completion of the finished product. I hereby warrant that I am of full legal age and have every right to contract in my own name in the above regard. I state further that I have read the above CONSENT and RELEASE prior to its execution, and that I am fully familiar with the contents thereof. This agreement shall be binding upon me and my heirs, legal representatives, and assigns. [FOR MINORS ONLY] If you are under 18 years of age, your parent or legal guardian must complete this Consent and Release Form on your behalf and provide the information requested below. [FOR PARENTS/GUARDIANS OF MINORS] I certify that I am the parent or legal guardian and I hereby make the certifications, licenses, and releases above on behalf of and with respect to my minor child. I agree that I have read this document completely, and I understand its contents.
Check here to consent
I do not consent
Story/Image Selection Criteria: HEALTH DATA*As stated above, when we choose stories to highlight publicly, we make efforts to ensure there is diversity of representation. Please let us know, by marking your selection below, whether you consent to our using your HEALTH information as selection criteria for using your story and/or image.
I DO authorize ACS to use my health information as story and/or image as selection criteria
I DO NOT authorize ACS to use my health information as story and/or image as selection criteria
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