Chase The Victory Circles Family Nights Registration Form
Our Mission: To strengthen and support families grieving the loss of a child, families fighting childhood cancer, and to inspire hope and kindness. Our Vision: To create a world where no grieving child or family walks alone — where every family has access to lifelong healing, hope, and support.
Welcome to Chase The Victory
Thank you for your interest in our program for grieving children and families in our community. Chase The Victory Family Nights provide structured support, healing, and connection for families with children ages 5-18 who have experienced the loss of a sibling or parent. Family Nights are peer support evenings for the whole family and includes a family dinner, yoga and other wellness activities, peer small groups, and other times of meaningful connection in age appropriate groups for children, teens, and parents/caretakers.
Our Family Name (Example: The Smith Family)
*
Tell us about your loss:
In this section share the information of the person who died
Tell us their name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Date of Death
*
-
Month
-
Day
Year
Date
Age at Death:
*
Cause of Death:
*
Diagnosis (if applicable):
Back
Next
Tell us about the Children you are registering:
Child #1 Information
Child #1 Name
*
First Name
Last Name
Gender
*
Please Select
Male
Female
School
*
Grade
*
Birthdate
*
Current Age
*
Child's age when person died
*
Relationship to child
*
Child #2 Information
Child #2 Name
First Name
Last Name
Gender
Please Select
Male
Female
School
Grade
Birthdate
Current Age
Child's age when person died
Relationship to child
Child #3 Information
Child #3 Name
First Name
Last Name
Gender
Please Select
Male
Female
School
Grade
Birthdate
Current Age
Child's age when person died
Relationship to child
Child #4 Information
Child #4 Name
First Name
Last Name
Gender
Please Select
Male
Female
School
Grade
Birthdate
Current Age
Child's age when person died
Relationship to child
Child #5 Information
Child #5 Name
First Name
Last Name
Gender
Please Select
Male
Female
School
Grade
Birthdate
Current Age
Child's age when person died
Relationship to child
Back
Next
Parent/Guardian Information
Parent/Guardian #1 Name
*
First Name
Last Name
Parent/Guardian #1 Relationship to Child:
*
Gender
*
Please Select
Male
Female
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Parent/Guardian #2 Name
First Name
Last Name
Parent/Guardian #2 Relationship to Child:
Gender
Please Select
Male
Female
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
E-mail
example@example.com
How did you hear about Chase The Victory? Select all that apply:
*
Chase The Victory Family
Chase The Victory Volunteer
Chase The Victory Board Member
My School*
Counselor/Therapist
Friend/Family Member/Co-worker
Hospital
Internet Search
Pediatrician/Primary Care Physician
Church/Place of Worship
Other
*If you heard about Chase The Victory from school, please specify
Back
Next
Continue
Continue
Media Release
I, the undersigned, hereby give my permission to CHASE THE VICTORY and/or its representatives to use or publicly display our family’s photographs, audio or video recordings and to use our names, these images or voice recordings in publications, slides, videos, motion pictures or on online without further notice. I understand that these visual images and voice recordings will be used to inform families, volunteers, donors, the media and general public about CHASE THE VICTORY’S mission, programs, services and events. I gladly give this authorization to support the efforts of CHASE THE VICTORY. I understand that this authorization shall continue until terminated in writing. This form must be signed by each adult and child 18 years of age or older.
Waiver of Liability and Release
I, the undersigned, hereby release and forever discharge CHASE THE VICTORY from any and all liability, claims, and causes in action, which arise or may hereafter arise or are in any way connected to our family’s involvement in a retreat. I understand that this Agreement discharges CHASE THE VICTORY from any liability or claim that we may have against CHASE THE VICTORY with respect to any bodily injury, personal injury, illness, death, or property damage that may result from involvement in a Retreat. I, the undersigned, also understand that CHASE THE VICTORY does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness.
Indemnification and Hold Harmless
I hereby agree to indemnify and hold harmless CHASE THE VICTORY from any liability, claims, and causes in action, which are in any way connected to involvement in a retreat.
Medical Care
I hereby release and forever discharge CHASE THE VICTORY from any liability, claims, and causes in action that arise or may hereafter arise on account of any first aid, treatment, or service rendered or not rendered in connection with a Retreat.
Should be Empty: