EmailMe Form - 2024 Holiday Family Day

Have you attended one of our events before? *

How many children will be attending? *

Name of Child 1: *

First Last

Age of Child 1: *

Ethnicity/Race of Child 1: *

Name of Child 2:

First Last

Age of Child 2:

Ethnicity/Race of Child 2:

Name of Child 3:

First Last

Age of Child 3:

Ethnicity/Race of Child 3:

Name of Child 4:

First Last

Age of Child 4:

Ethnicity/Race of Child 4:

Name of Child 5:

First Last

Age of Child 5:

Ethnicity/Race of Child 5:

Name of Child 6:

First Last

Age of Child 6:

Ethnicity/Race of Child 6:

Address: *

Street Address City State / Province / Region Postal / Zip Code

How many adult family members will be attending with the child? *

Adult 1: Name *

First Last

Adult 1: Relationship to Child *

Adult 1: Ethnicity/Race *

Adult 1: Phone Number *

### - ### - ####

Adult 1: Email Address *

Adult 2: Name

First Last

Adult 2: Relationship to Child

Adult 2: Ethnicity/Race

Adult 2: Phone Number

### - ### - ####

Adult 2: Email Address

Adult 3: Name

First Last

Adult 3: Relationship to Child

Adult 3: Ethnicity/Race

Adult 3: Phone Number

### - ### - ####

Adult 3: Email Address

Adult 4: Name

First Last

Adult 4: Relationship to Child

Adult 4: Ethnicity/Race

Adult 4: Phone Number

### - ### - ####

Adult 4: Email Address

Does anyone attending have a food allergy or dietary restriction? If yes, please explain. *

Information About Your Child’s Loss:

To better support your child and their needs during the event, please provide some information about their experience with loss. This will help us tailor our activities and support to be as meaningful as possible.

Please rest assure that all information will be kept confidential and used solely to provide the best experience and support for your child.

Briefly describe the nature of your child’s loss: *

How recent was the death? (e.g., within the past month, within the past year, over a year ago): *

VIDEO/PHOTOGRAPH RELEASE

I hereby grant The Hospice of Baton Rouge the irrevocable right and permission to use photographs and/or video recordings of me at events such as Camp Conquer, Family Day, or other events and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me.

I understand and agree that such photographs and/or video recordings of me may be placed on the Internet. I also understand and agree that I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of me. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of The Hospice of Baton Rouge.

I hereby release, acquit and forever discharge the State of Louisiana, The Hospice of Baton Rouge, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.

I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives. *

Yes

No

Signature

Clear