Magic Moments Digital Application Step 1 of 3 33% 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 NO 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 NumberFather/Guardian First Last Father/Guardian Employer Father/Guardian Work NumberWho Has Custody?(Required) Mother Father Both Other If other, please state who has custody: Does legal guardian have valid driver's license? Yes No Select All(State/License Number) Is the child a U.S. Citizen?(Required) Yes No Child's Diagnosis(Required) Child's Primary Physician for Diagnosis(Required) Physician's Phone(Required)Physicians FaxPhysician'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 No When was he/she diagnosed?(Required) Frequency of hospital/clinic visits?(Required) Has he/she missed school due to the illness?(Required) Yes No 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 No Are any of your other children eligible for a magic moment?(Required) Yes No MAGIC MOMENT REQUEST: (List top 3 - only one will be granted) Travel is limited to Continental United States only.(Required) Add RemoveIf magic moment involves travel, it will include only 2 adults and siblings 18 and under living in the home.(Required) Add RemovePlease include first and last names, DOB, and relation to childSignature(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 Δ