Georgia Community DREAM ON 3

The following section should be completed by the applicant's parents or legal guardians.

Community*

Georgia

Applicant's First Name

Applicant's Middle Name

Applicant's Last Name

Date of Birth

Date

Age

Male

Female

Street Address

City

State

Zip Code

County

Applicant's Medical Diagnosis

Allergies

Medical Considerations

OxygenWheelchairOther

If Other, please explain

Parent or Legal Guardian Info

First NameLast Name

Phone number

Email address

example@example.com

I completely understand and fully agree with the following: 1 Dream On 3,or any representative of Dream On 3,has made no promises or assurances to the applicant, parents/ legalguardians, or potential participants regarding the requested Day Dream. 2 Dream On 3reserves the right to approve or deny any application or request for any reason, with or without cause. 3 Prior to receiving any benefits from Dream On 3, all Day Dream applications must receive approval from Dream On 3 management and as needed, the child's treating physician. 4 All Day Dream applicants agree to abide by and adhere to all conditions, requirements, qualifications, and restrictions as designated by Dream On 3. 5 All individuals with parental or custodial rights for the Day Dreamapplicant must approve and sign all required documents before the Day Dream is granted. 6 Permission is granted to DO3 to take pictures and use within social media & on DO3 website. 7Dream On 3 will be adhering to all COVID-19 guidelines & precautions and we ask that your family do the same.

In consideration for DREAM ON 3 providing services and/or facilities to the Day Dream applicant and allowing me, my child(ren) to participate and/or observe the Day Dream, I agree to the following:

Liability Release-Participants understand that involvement in the Day Dream may entail risk of injury or harm to the Participants and agree that this risk is fully assumed by the Participants. In addition I, and on behalf of my child(ren) agree to forever release and discharge the DREAM ON 3 from and agree not to sue the DREAM ON 3 for any and all liability or claims I and/or my child(ren) may have for any property damage and loss, personal injury. emotional distress, illness, disability, and death, related to me,and/or my Child(ren)'s participation in the Day Dream or use of any equipment or facilities. This release is for any type of claim, including breach of contract, fraud, or any other type of suit and includes personal injury and property losses alleged to be caused by the negligence of DREAM ON 3 to the fullest extent permitted by law.

Parent/LegalGuardian Signature

Date

Print Name

Number of Immediate Family Members Attending Day Dream (Including Applicant)

Organization providing application:

Georgia Community Dream On 3 DAY DREAM FORM