Cannot select choice! The maximum number of choices has been selected.Value removed!

Loading...

Patient Information
	Date of Application TodayM-D-Y
	How many attendees are you registering who currently receive care at Children's? Please fill out their information below. * must provide value 12345
	Patient #1
	First Name
	Last Name
	Age
	Campus in which ______ received treatment. Egleston Hughes Spalding Scottish Rite Egleston Hughes Spalding Scottish Rite reset
	Patient #2
	First Name
	Last Name
	Age
	Campus in which ______ received treatment. Egleston Hughes Spalding Scottish Rite Egleston Hughes Spalding Scottish Rite reset
	Patient #3
	First Name
	Last Name
	Age
	Campus in which ______ received treatment. Egleston Hughes Spalding Scottish Rite Egleston Hughes Spalding Scottish Rite reset
	Patient #4
	First Name
	Last Name
	Age
	Campus in which ______ received treatment. Egleston Hughes Spalding Scottish Rite Egleston Hughes Spalding Scottish Rite reset
	Patient #5
	First Name
	Last Name
	Age
	Campus in which ______ received treatment. Egleston Hughes Spalding Scottish Rite Egleston Hughes Spalding Scottish Rite reset
Parent(s)/Guardian(s) Information
	Total Number of Parents / Guardians Attending * must provide value 1 2 3 4 1 2 3 4 reset
	Parent/Guardian Name * must provide value
	Parent/Guardian's Relationship to attendee * must provide value
	Parent/Guardian Email Address * must provide value A confirmation email will be sent to this email so please provide a valid email address.
	Parent/Guardian Phone Number * must provide value
	Additional Parent/Guardian Information
	Parent/Guardian Name * must provide value
	Parent/Guardian's Relationship to Camper * must provide value
	Parent/Guardian Email Address * must provide value A confirmation email will be sent to this email so please provide a valid email address.
	Parent/Guardian Phone Number
Additional Guests Information
	Total Number of Additional Guests Attending * must provide value 012345678
	Guest #1
	Please give us the name of the first guest. * must provide value
	Please give us the age of the this guest. * must provide value
	Guest #2
	Please give us the name of the second guest. * must provide value
	Please give us the age of the this guest. * must provide value
	Guest #3
	Please give us the name of the third guest. * must provide value
	Please give us the age of the this guest. * must provide value
	Guest #4
	Please give us the name of the fourth guest. * must provide value
	Please give us the age of the this guest. * must provide value
	Guest #5
	Please give us the name of the fifth guest. * must provide value
	Please give us the age of the this guest. * must provide value
	Guest #6
	Please give us the name of the sixth guest. * must provide value
	Please give us the age of the this guest. * must provide value
	Guest #7
	Please give us the name of the seventh guest. * must provide value
	Please give us the age of the this guest. * must provide value
	Guest #8
	Please give us the name of the eighth guest. * must provide value
	Please give us the age of the this guest. * must provide value
Food Allergies
	Lunch will be generously provided by Chick-fil-A. Please let us know if you or your group have any special food needs or allergies. Expand
Media Consent
	CONSENT FORM AND WAIVER (PATIENT & FAMILY) AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH AND OTHER PERSONAL INFORMATION AND/OR PUBLIC USE OF IMAGE (PHOTOGRAPH OR VIDEO) FORMARKETING PROMOTION, MEDIA AND PUBLIC RELATIONS PURPOSES I hereby give consent to Children's Healthcare of Atlanta Inc. (hereinafter "Children's"), its affiliates, media outlets, community organizations, and/or third parties providing service to Children's to take and use images (photographs or video) or sounds recordings of me and/or the minor patient/person named below for whom I am giving consent (hereinafter the "Patient"), and to disclose such information in any Children's and/or third party media outlet, including radio, television, internet, social media, or print. I understand that the intended use of such images and information may be for advertising, marketing, fundraising or promotional purposes of Children's. I understand that the information to be disclosed may include protected health information about the Patient's treatment at Children's obtained from interviews of the family, physicians and hospital personnel, or from the patient's medical records. I hereby waive the right to or interest in the confidentiality of this information or images taken and disclosed to the public, as contemplated in this release. I understand that the information disclosed pursuant to this release may be re-disclosed and no is longer protected by any federal or state privacy regulations. I acknowledge that this consent and authorization for release of confidential information is being made solely for the benefit of Children's and without any expectation of compensation or other benefit to the Patient or the family thereof. While unlikely, Children's may receive direct or indirect remuneration from a third party. To the extent that any benefit accrues or might accrue to Children's from the use of images or disclosure of information, I hereby and forever waive any interest in or claim to such benefits. I hereby release and forever discharge Children's (including without limitation all corporate affiliates and officers, directors, trustees, employees, medical staff members and agents) from any and all claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to, or in any way connected with the use of images or disclosure of the information and materials described herein, and I hereby waive all rights and interest in and to such information and materials. I understand that I may refuse to sign this authorization, that it is strictly voluntary and that my treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this release. I have been informed that this authorization is voluntary and is subject to revocation at any time, except to the extent that action has been taken in reliance thereon, by notifying Children's in writing at: MediaConsents@choa.org. Expiration: Authorization is ongoing until Patient reaches age of majority (18yo) unless otherwise revoked. I agree to the Photographs and Videotape Consent and Release Agreement above. * must provide value Yes No Yes No reset
	Please sign below to confirm that you agree to the media consent information above. * must provide value ( MB) Add signature
	Date of Signature * must provide value TodayM-D-Y
	Survey Upload	( MB) Upload file
	Number of People Attending   View equation
	Email Trigger	Yes Yes reset
Submit