Fall For Hearts Registration Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Text me about upcoming CHD events!!

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Email

example@example.com

I am a parent or caregiver for a CHD child.

CHD Child's Name

First NameLast Name

CHD Diagnosis:

How many siblings will be attending?

Please list names and ages of all children attending:

Please provide meal selections below

BBQ Sandwiches and Chips

Hotdog and Chips

PB&J and Chips

Standard Photo & Video Release Form

I hereby authorize Kerrington's Heart, Inc. to publish the photographs and video's taken of me and/or the registered minor children as well as our names for use in Kerrington's Heart, Inc. printed publications, website, and social media. I release Kerrington's Heart, Inc. from any expectation of confidentiality for minor children and myself. I attest that I am the parent or legal guardian of the children listed above and that I have the authority to authorize Kerrington's Heart, Inc. to use their photographs, videos, and names. I acknowledge that since participation in publications and websites produced by Kerrington's Heart, Inc. is voluntary, neither the minor children nor I will receive financial compensation. I further agree that participation in any publication and website produced by Kerrington's Heart, Inc. confers no rights of ownership whatsoever. I release Kerrington's Heart, Inc., its board members, and volunteers from liability for any claims by me or any third party in connection with my participation or the participation of the listed minor children. By signing your name in the box below you are agreeing to the above release.

Signature