Magic Moments Digital Application

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HAS YOUR CHILD RECEIVED A WISH FROM MAGIC MOMENTS OR ANY OTHER WISH-GRANTING ORGANIZATION?(Required)

A child who has received a wish before is not eligible for a magic moment.

YES

Child's Name(Required)

First Last

Child's Sex(Required)

Male

Female

Age(Required)

Child's DOB(Required)

MM slash DD slash YYYY

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(Required)

County School T-Shirt Size

Cell Phone(Required)

Email(Required)

Alternate Email

Caring Bridge or FB Page

Mother/Guardian

First Last

Mother/Guardian Employer

Mother/Guardian Work Number

Father/Guardian

First Last

Father/Guardian Employer

Father/Guardian Work Number

Who Has Custody?(Required)

Mother

Father

Both

Other

If other, please state who has custody:

Does legal guardian have valid driver's license?

Yes

(State/License Number)

Is the child a U.S. Citizen?(Required)

Yes

Child's Diagnosis(Required)

Child's Primary Physician for Diagnosis(Required)

Physician's Phone(Required)

Physicians Fax

Physician's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Child's Social Worker (If Applicable)

First Last

Is your child cognizant he/she is receiving/making a magic moment?(Required)

Yes

When was he/she diagnosed?(Required)

Frequency of hospital/clinic visits?(Required)

Has he/she missed school due to the illness?(Required)

Yes

If yes, how many days missed during the last 6 months?

Does your child use a wheelchair as his/her primary means of mobility?(Required)

Yes

Are any of your other children eligible for a magic moment?(Required)

Yes

MAGIC MOMENT REQUEST: (List top 3 - only one will be granted) Travel is limited to Continental United States only.(Required)

If magic moment involves travel, it will include only 2 adults and siblings 18 and under living in the home.(Required)

Please include first and last names, DOB, and relation to child

Signature(Required)

I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS CORRECT.

Our Story:(Required)

Why did your child select this particular magic moment:(Required)

Any additional information you would like to share with us:(Required)

How did you hear about Magic Moments?(Required)

Please Upload a Photo of your Child(Required)

Max. file size: 400 MB.

Release:(Required)

I agree to the privacy policy.

In consideration of the furnishing of goods and/or services to me and/or my child or ward, I hereby release, discharge, and agree to indemnify and hold harmless Magic Moments, an Alabama non-profit corporation, its directors, officers, members, employees and volunteers, and each of their respective legal and financial representatives (hereinafter collectively referred to as “Magic Moments”) of, from and against all claims, demands, actions, judgments and executions which I ever had, or now have, or may have in the future, or which my child or ward or my above-named child’s or ward’s heirs, legal representatives or assigns may have in the future, arising or resulting from, or in any manner pertaining or incidental to, Magic Moments’ furnishing of such goods and/or services to me and/or my said child or ward. I understand that Magic Moments is willing to provide such goods and/or services to me and/or my child or ward in consideration for my having released Magic Moments from any and all liability arising out of the furnishing of said goods and/or services to me and/or my child or ward. As further consideration for the providing and furnishing of goods and/or services to me and/or my child or ward, I hereby agree to indemnify and hold harmless Magic Moments from and against any and all further claims for damages, costs and expenses, by or on behalf of myself and/or my child or ward arising out of the above furnishing of goods and/or services to me and/or my child or ward. Specifically, should there ever be any claim made by me and/or by my child or ward against Magic Moments hereafter, it is my agreement to indemnify and hold harmless Magic Moments against any and all such claims, damages, costs and expenses. I hereby authorize (i) my physician(s) to release information about me and/or my child or ward, including, without limitation, individually identifiable health information, protected health information, and other personally identifiable information (collectively, “Personal Information”), that may be reasonably necessary or appropriate for carrying out a magic moment and/or providing goods and/or services, and (ii) Magic Moments to use and to disclose such Personal Information as may be reasonably necessary or appropriate for carrying out a magic moment and/or providing goods and/or services, and (iii) Magic Moments to aggregate Personal Information regarding its magic moments applicants and to disclose such aggregated Personal Information to other wish-granting organizations. I have read this release and understand its terms. I execute it voluntarily and with full knowledge of its significance.

Media Release:(Required)

I do consent for me and for my child or ward, to be photographed, filmed and/or interviewed, and further agree that this material may be used for promotional or educational purposes in publications, television broadcasts, print media, Magic Moments’ newsletter (including e-newsletter), website and/or Facebook page. I hereby release Magic Moments of all liability in its actions under this permit.

I agree to the privacy policy.

Media Release(Required)

Magic Moments has the right for me and for my child or ward to be photographed, filmed and/or interviewed, and further agree that this material may be used for promotional or educational purposes in publications, television broadcasts, print media, Magic Moments’ newsletter (including e-newsletter), website and/or Facebook page. I hereby release Magic Moments of all liability in its actions under this permit.

I do consent

I do not consent