Magic Moments Digital Application

Child's Name(Required)

First Last

Child's Sex(Required)

Male

Female

Age(Required)

Child's DOB(Required)

Home Address(Required)

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

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

No

(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 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

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)

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

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: 64 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)

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

COVID-19 LIABILITY WAIVER(Required)

The novel coronavirus, also known as Coronavirus/COVID-19 (“COVID-19”) has been declared a worldwide pandemic by the World Health Organization. I acknowledge the highly contagious nature of COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that the organization has been in contact with the wish child's primary care physician to obtain information regarding his/her medical condition and risk category relative to COVID-19. I further acknowledge that the organization cannot guarantee that my wish child, accompanying minors and I will not become infected with COVID-19. I understand that the risk of becoming exposed to and/or infected by COVID-19 may result from the actions, omissions, or negligence of myself and my family members and others. I voluntarily seek travel and other accommodations arranged by the organization and acknowledge that I am increasing the risk of exposure to COVID-19 for my wish child, accompanying minors and myself. I acknowledge that I shall comply with all set procedures to reduce the spread while on my child's wish trip.

I attest that: * Wish Child, Accompanying Minors and I are not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. * Wish Child, Accompanying Minors and I have not traveled internationally within the last 14 days. * Wish Child, Accompanying Minors and I have not traveled to a highly impacted area within the United States of America in the last 14 days. * I do not believe that my Wish Child, Accompanying Minors and I have been exposed to someone with a suspected and/or confirmed case of COVID-19 or to anyone experiencing any of the symptoms above described. * Wish Child, Accompanying Minors and I have not been diagnosed with COVID-19. * Wish Child, Accompanying Minors and I are following all CDC recommended guidelines as much as possible and limiting our exposure to COVID-19.

I hereby release, covenant not to sue, discharge, and agree to hold the Organization absolutely harmless of and from, and waive on behalf of myself, my Wish Child, Accompanying Minors, my heirs, and any personal representatives any and all actions, causes of action, liabilities, claims, demands, damages, costs, expenses and compensation for illness, bodily injury, death, medical treatment, damage or loss to myself, my Wish Child, Accompanying Minors and/or property of any of us that may be caused in whole or in part by any act, or failure to act of the Organization, or that may otherwise arise in any way in connection with any services, accommodations, or arrangements received from or provided by the Organization. I understand that this release discharges the Organization from any liability or claim that I, my Wish Child, Accompanying Minors, heirs, or any personal representatives may have against the Organization with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services, accommodations, or arrangements provided by or received from the Organization. This liability waiver and release extends to, and each reference in this release to the “Organization” above refers to and includes, each of the Organization’s agents, officers, directors, contractors, servants, employees, parents, subsidiaries, members and affiliates (collectively the organization’s affiliated persons) and each of their successors, heirs, assigns and representatives the organization.

I/we hereby agree, represent, and warrant that I/we have read the foregoing release and have executed it freely and voluntarily.

I agree to the privacy policy.