Champion Day Experience Intake Form

Please Note: Eligibility for the Champion Day Experience is limited to those who are currently in treatment or have completed treatment within the past 2 years.

Child's Name*

First NameLast Name

Date of Birth*

Age*

Gender*

Diagnosis*

Currently In Treatment*

YesNo

Treatment Completed*

YesNo

Date of Treatment Completion*

Where is the child currently at with treatment?*

Parent/Guardian Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail*

example@example.com

Marital Status*

Number of Siblings*

Family Income Level*

Does your household receive federal health insurance assistance?*

YesNo

Please select one of more of the choices as appropriate*

Child's favorite Team, Sport, Athlete, or Hobby:*

Has child ever been granted an experience by a sports team?*

YesNo

If yes, please indicate the organization's name, experience, and date it was or will be granted.*

Child's Shirt Size*

Please note Mitchell Thorp Foundation cannot guarantee the participation of any individuals listed below.

List of Requested Participants (Legal Name, Relationship to Child, Age)*

Social Media: Mitchell Thorp Foundation would like to stay connected through social media. If Interested, please provide your social media handles below.

Instagram

Facebook

Would you like us to contact you about our other programs and resources?*

YesNo

LIABILITY RELEASE

Participants understand that involvement in the experience may entail risk of injury or harm to the participants and agree that this risk is fully assumed by the participants. In addition, and in consideration of Mitchell Thorp Foundation considering the Experience and, if it so determines,
granting the Experience, the Participants hereby release and agree to hold Mitchell Thorp Foundation harmless for, from and against any and all liability, damages, and claims (“Claims”) of any kind, known and unknown, which may be connected with, result from, or arise out of the consideration, preparation, fulfillment, or participation in the Experience. This includes, but is not limited to, claims involving economic loss, illness or medical condition, accidental injury, or death.

LIABILITY RELEASE AND AUTHORIZATION RE: PUBLICITY

The undersigned have requested that the Mitchell Thorp Foundation and their respective volunteers, officers, directors, employees and agents ("Mitchell Thorp Foundation") fulfill an experience (the “Experience”) for the Child and the following people (collectively, “Participants”) have requested that Mitchell Thorp Foundation allow them to participate in the experience. Participants, and the parents or legal guardians of the child and any minor participants, are signing this Liability Release and Authorization Re: Publicity (“Release and Authorization”) to bind themselves, their minor children, their heirs, successors, assigns, and estates to the conditions described herein.

Indicate names of potential experience participants:*

PUBLICITY AUTHORIZATION

Participants understand and agree that fulfillment of the experience may result in publicity, whether or not the Mitchell Thorp Foundation actively takes steps to publicize the experience. However, to the extent the Mitchell Thorp Foundation has control over the matter, child’s parents or guardians are asked to choose between the following two alternatives. [Note: By signing this Release and Authorization, all other Participants (or their parents/guardians if under the age of 18) agree to be bound by the “publicity option” chosen by Child’s parents or legal guardians.]

Choose one*

OPTION 1 [Publicity O.K.]: Participants authorize Mitchell Thorp Foundation to publicize the Experience and to use Participants’ names, likenesses and other information about Participants and the Experience (including Child’s medical condition), whether embodied in photographs, videotapes, recordings or any other format (collectively, “Information”), for purposes of promotion, publication, commercial advertising, or any other purpose whatsoever, now or at any time in the future. Participants understand and agree that Mitchell Thorp Foundation may use any such Information: (1) in all manner and media whatsoever, whether now known or hereafter invented, including electronic and print media and the Internet; (2) with or without Participants’ names; (3) without the payment of royalties or other compensation to anyone; and (4) without the need to notify them or to seek further approval before doing so.OPTION 2 [Prefer no publicity]: Participants request that information about their involvement in the Experience not be actively publicized by Mitchell Thorp Foundation to the electronic or print news media, posted on the Internet, or used in Mitchell Thorp Foundation “collateral” such as newsletters, brochures, annual reports, etc. However, each Participant understands and agrees: (1) that information regarding the Experience and Participants will necessarily be discussed with and disclosed to those involved in the process; (2) that Mitchell Thorp Foundation may publicly describe and promote the Experience generally, without specifically identifying Participants; and (3) that even if Mitchell Thorp Foundation does not actively publicize the Experience, the general public and media may obtain information concerning Participants’ involvement in the Experience from other sources.

Signature of Child's Parent/Guardian*

Date*

Date

Participants acknowledge reading and understanding this release and authorization. For the child and any minor participants, the signature of their parent or guardian is on behalf of the parent/guardian and on behalf of the minor. Participants agree that this release and authorization fully and accurately expresses their understanding and has not been modified orally or in writing.

I understand and agree.
1. That no promises or assurances whatsoever have been made to me by any representative of Mitchell Thorp Foundation regarding the requested experience;
2. That the granting of any experience and the participation of any person in the experience are contingent upon approval by Mitchell Thorp Foundation and the child’s physician, as well as full compliance with all conditions, qualifications, and restrictions designated by Mitchell Thorp Foundation;
3. That all individuals with parental or custodial rights for the child must approve the experience before it is granted and must sign all necessary documents; and that the receipt of an experience may impact the eligibility for public assistance and/or benefits.
I promise that the information provided by me is true and complete to the best of my knowledge.

Date

Parent/Legal Guardian of Child*

First NameLast Name