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Enroll in A Kid Again

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Step 1 of 5 - Child's Information

20%

Thank you for your interest in becoming part of the A Kid Again family. Families can enroll from anywhere, and we are proud to serve families across many communities. We currently do not offer any transportation services or reimbursement. If you do not see a metro area close to you and would like information in the future, please select "no metro area near me" to be added to our mailing list.

Please complete the following application for your child with a life-threatening condition. Once submitted, our Medical Advisory Committee will review and may request some additional information depending on diagnosis information. If you have more than one child who you think would qualify, please notate that on the sibling information portion of the application. Our team may reach out to follow-up with any questions regarding your child(ren)'s diagnosis.

Please select the metro area closest to you/to which you would be willing to travel for Adventures.*

Join the Chapter Waitlist

Child's full name*

First Middle Last Suffix

Date of Birth*

Child's Date of Birth

Month

Day

Year

Gender*

Male

Female

Non-Binary

Other

Please select the Diagnosis Category/Hospital Department that relates to your child's diagnosis*

Example: Neurology Department for an Autism Spectrum Disorder diagnosis or Medical Genetics for Chromosome Disorder diagnosis.

Please select the specific name of your child's condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis*

Does your child have a secondary diagnosis?*

Yes

Secondary Diagnosis

Please select the Diagnosis Category/Hospital Department that relates to your child's diagnosis*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis.*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis.*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis.*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis.*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis.*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis.*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis.*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis.*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis.*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis.*

Please select the specific name of your child’s condition from the drop down box*

The drop-down list varies based on hospital department selected. If you cannot locate your child’s diagnosis, please select “other”.

Type the specific name of your child’s diagnosis.*

If your child has more than two diagnoses, please email us the diagnoses information at [email protected]

Hospital/Doctor/Social Worker Information

Hospital Providing Care*

Other Hospital or Medical Center*

Name of Medical Professional Providing Care

Please provide the child life specialist, doctor, nurse practitioner, or social worker who provides care to your child.

First Last

Medical Professional Contact Information

Please provide an email address or phone number for the medical professional you listed above.

Additional Diagnosis Information

Does your child receive care from hospice, palliative care, or a complex care unit?*

Yes

Please select all/any services or treatments that have been RECOMMENDED for your child in the PAST 3 YEARS:

Pulmonary/Breathing*

At-home Oxygen

CPAP/BiPAP (machine that helps you breathe at night)

Tracheostomy tube (tube in neck that helps you breathe - no breathing machine needed)

Ventilator

Monthly shots to treat asthma

Other Pulmonary/Breathing (please specify below)

None of the above - Pulmonary/Breathing

Cardiology/Heart*

Pacemaker

Open-heart Surgery

Other Cardiology/Heart (please specify)

None of the above - Cardiology/Heart

Neurology/Brain

Brain Shunt

More than 2 different seizure medications (not including rescue medication)

Treatment for a stroke

Device to help your child speak/communicate

Other Neurology/Brain (please specify)

None of the above - Neurology/Brain

Gastroenterology/Eating*

Feeding Tube

TPN

Extremely Strict/Specific Diet

Other Gastroenterology/Eating (please specify)

None of the above - Gastroenterology/Eating

Hematology/Blood*

More than 2 blood/platelet transfusions in 1 year

Indwelling line/port

Other Hematology/Blood (Please specify)

None of the above - Hematology/Blood

Orthopedics/Bones & Muscles*

Medicine shots or infusions more than 4 times a year - Orthopedics/Bones & Muscles

Wheelchair/Walker

Other Orthopedics/Bones & Muscles (Please specify)

None of the above - Orthopedics/Bones & Muscles

Endocrine/Metabolic (how the body uses food and hormones)*

Daily Insulin

Medicine shots or infusions more than 4 times a year - Endocrine/Metabolic

Other Endocrine/Metabolic (Please specify)

None of the above - Endocrine/Metabolic

Nephrology/Kidneys & Bladder*

Dialysis

Daily Catheterization

Other Nephrology/Kidneys & Bladder (Please specify)

None of the above - Nephrology/Kidneys & Bladder

Immunology (how the body fights infection)*

Medicine shots or infusions more than 4 times a year - Immunology

Other Immunology (Please specify)

None of the above - Immunology

Oncology/Cancer*

Chemotherapy

Radiation Therapy

Other Oncology/Cancer (Please specify)

None of the above - Oncology/Cancer

Please specify what other service/treatment for which your child qualified:

Please check all the boxes for what your child has needed in the past 1 year:*

Qualifies for Home Nursing

Has had to stay in the hospital overnight more than 7 days

Has needed to stay in the intensive care unit (ICU) for more than 1 day

If your child is 5 or older, have they not been able to attend in-person school due to illness

If your child is 5 or older, do they qualify for 24/7 health aide, nurse, or parent supervision to keep them safe

None of the above

Address*

Street Address Address Line 2 City State ZIP Code

Alabama County*

Alaska County*

Arizona County*

Arkansas County*

California County*

Colorado County*

Connecticut County*

Delaware County*

District of Columbia County*

Florida County*

Georgia County*

Hawaii County*

Idaho County*

Illinois County*

Indiana County*

Iowa County*

Kansas County*

Kentucky County*

Louisiana Parish*

Maryland County*

Massachusetts County*

Michigan County*

Minnesota County*

Mississippi County*

Missouri County*

Montana County*

Nebraska County*

Nevada County*

New Hampshire County*

New Jersey County*

New Mexico County*

New York County*

North Carolina County*

North Dakota County*

Ohio County*

Oklahoma County*

Oregon County*

Pennsylvania County*

Rhode Island County*

South Carolina County*

South Dakota County*

Tennessee County*

Texas County*

Utah County*

Vermont County*

Virginia County*

Washington County*

West Virginia County*

Wisconsin County*

Wyoming County*

Parent/Guardian Name*

This will be the primary contact for child and all A Kid Again Communication including all Adventure invites.

First Last Suffix

Parent/Guardian Mobile Phone*

Parent/Guardian Email*

Parent/Guardian Birth Date*

Month

Day

Year

Parent/Guardian Gender*

Male

Female

Non-Binary

Other

Is there an additional Parent/Guardian who lives in the same house?*

All Parent/Guardians who live in the same household will need to be listed on the application to be eligible to attend Adventures.

Yes

Additional Parent/Guardians

Parent/Guardian Name*

First Last Suffix

Parent/Guardian Mobile Phone*

Parent/Guardian Birth Date*

Month

Day

Year

Parent/Guardian Gender*

This field is hidden when viewing the form

Sibling 7 Relationship

This field is hidden when viewing the form

Sibling 7 Reciprocal

Sibling Name*

First Last

Sibling Birth Date*

Month

Day

Year

Sibling Gender*

Male

Female

Non-Binary

Other

This field is hidden when viewing the form

Sibling Information 8

Sibling Name*

First Last

Sibling Birth Date*

Month

Day

Year

Sibling Gender*

Male

Female

Non-Binary

Other

This field is hidden when viewing the form

Sibling Information 9

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Sibling 9 Relationship

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Sibling 9 Reciprocal

Sibling Name*

First Last

Sibling Birth Date*

Month

Day

Year

Sibling Gender*

Male

Female

Non-Binary

Other

This field is hidden when viewing the form

Sibling Information 10

Sibling Name*

First Last

Sibling Birth Date*

Month

Day

Year

Sibling Gender*

Male

Female

Non-Binary

Other

This field is hidden when viewing the form

Sibling Information 11

Sibling Name*

First Last

Sibling Birth Date*

Month

Day

Year

Sibling Gender*

Male

Female

Non-Binary

Other

This field is hidden when viewing the form

Sibling Information 12

Sibling Name*

First Last

Sibling Birth Date*

Month

Day

Year

Sibling Gender*

Male

Female

Non-Binary

Other

Foster Parents

Are you foster parents for other children or any of those listed above?*

Please note: We must receive a copy of the legal documents if you have custody of someone else’s child(ren), or if you are a foster parent of a child prior to their participation in A Kid Again.

Yes

Please upload legal documentation.*

Acceptable file formats are jpg, png, or pdf

Accepted file types: jpg, png, pdf, Max. file size: 100 MB.

Personal Information

We collect this data for grant applications that will help provide more Adventures and support for our families. Grants may ask for demographic information such as income, race, religion, school district, etc.

Race of enrolled child*

White, Non-Hispanic

African American

Latino

American Indian/Alaska Native

Asian

Pacific Islander

Middle Eastern

I'd prefer not to answer Race of Enrolled Child

Other

This field is hidden when viewing the form

Race of enrolled child (old)*

White, Non-Hispanic

African American

Latino

American Indian/Alaska Native

Asian

Pacific Islander

Middle Eastern

Other Race (specify below)

I'd prefer not to answer Race of Enrolled Child

This field is hidden when viewing the form

Other (race of enrolled child): (Old)*

Annual Household Income*

Is your family enrolled in any of the below programs? (Select All That Apply)*

Medicaid

Childcare Assistance Programs

Cash Assistance Programs

HEAP Programs

Women, Infants & Children (WIC)

Supplemental Nutrition Assistance Program (SNAP)

N/A

Name of School enrolled child attends:

Name of health insurance carrier:*

Other (health insurance carrier):*

Do you have regular access to internet?*

Employer Information

During our Annual Corporate Fundraising Campaign we are routinely asked by corporations if any of our parents work for that particular corporation. Corporations are more likely to support a cause if they know that it will benefit their employees.

Employer for Parent/Guardian #1

Employer for Parent/Guardian #2

How did you hear about A Kid Again?*

An Enrolled A Kid Again Family

A Kid Again Staff/Board Member/Volunteer

Cardinal Kids

Social Media

Franklin County Health Department

Friend

Haslinger Family Pediatric Palliative Care Center

Hospital/Social Worker/Child Life Specialist/Nurse

Web Search

School

TV/Radio/News

Non-Profit Organization (Lis Below)

Other Referral (specify below)

Other: Please tell us how you heard about A Kid Again*

Please tell us about the Non-profit that referred you.*

Can any immediate family members be classified in one of these categories?*

Adopted Child(ren)

Blended Family

Guardianship

LGBTQ+

Military - Currently Enlisted

Military - Veteran

Single Parent

Does Not Apply

I'd prefer not to answer Family Categories

Primary Language spoken in household*

Arabic

English

French

Mandarin

Nepali

Sign Language

Somali

Spanish

Other

This field is hidden when viewing the form

Primary Language spoken in household*

Arabic

English

French

Mandarin

Nepali

Sign Language

Somali

Spanish

Other Primary Language (specify below)

This field is hidden when viewing the form

Please provide the Primary language spoken in your household*

Liability Waiver

By my signature set forth below, and in consideration of A Kid Again, taking myself, my spouse, my children and any or all of my family on any "A Kid Again" outings, I hereby release A Kid Again and all of its agents, officers, servants, directors, employees, the donors, contributors, volunteers, and or participants from any liability whatsoever, in connection with the preparation, execution, and fulfillment of any and all outings on behalf of the above-mentioned child. The scope of this release shall include but not be limited to transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs, and physical injury of any kind.

Additional Liability Release and Authorization

Promotional Materials and Social Media: In order to further its mission, A Kid Again, through its agents, directors, officers, servants, or employees, periodically photographs, films, and/or electronically records interviews with parents or guardians. Those materials may be distributed now or at any time in the future to anyone including the general public, magazines, radio stations, TV stations, newspapers, public presentations, social media, or other media outlets, or displayed on A Kid Again’s website. A Kid Again also maintains social media accounts on networks such as Facebook, Instagram, and X. Through these networks, A Kid Again desires to share posts welcoming new participants and posting photos and other information of participants at outings. This may include information regarding the participant’s name and/or medical condition. By my electronic acknowledgment set forth below, I further accept that A Kid Again or any of its agents, directors, officers, servants, or employees can photograph, film and/or electronically record interviews with me in such a manner that they choose. I further acknowledge A Kid Again and its partners may distribute these recordings/films/pictures, now or at any time in the future to anyone including the general public, to media outlets, in public presentations and on its social media channels. I understand that most A Kid Again events take place in a group setting, often in public venues. I hereby acknowledge that in no event will A Kid Again be held in anyway responsible for photographs, films, recordings, including social media posts, of me/us and my child taken by third parties at A Kid Again outings. I also understand that it is my responsibility to excuse my family from situations where it is reasonably understood that A Kid Again is photographing, filming, or electronically recording participants, and to promptly notify A Kid Again of my and my child’s non-participation. In the event I do not excuse ourselves or promptly notify A Kid Again of our non-participation, I hereby waive my and my child’s non-participation in that instance.

Media Policy Acknowledgement

I confirm that I have read and understand the above media policy.

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Media Policy Acknowledgement:

I confirm that I have read and understand the above media policy.

Research Studies

At times, the administration of A Kid Again (“AKA”) may initiate non-clinical research studies directed by our staff or through an outside research organization. These studies will help us evaluate AKA’s program by surveying family satisfaction and by analyzing the impact on the medial/psychosocial outcomes of the children who AKA serves. The goal of these studies is to ensure that AKA’s program is meeting the needs of the children and families it serves as well as to quantify its impact on treatment outcomes. By signing this consent form, you are agreeing to allow AKA staff members or their agents to contact you to discuss your family’s experience with AKA or to seek your specific consent to participate in a research study analyzing outcomes. AKA and its agents will keep any information regarding your child’s condition and treatment confidential, and neither AKA nor its agents will use or otherwise disclose information regarding your child’s condition or treatment for any other the purpose or to any other party.

Parent/Guardian Electronic Signature*

First Last

Signature Date*

Month

Day

Year

Are you an A Kid Again Staff Member or Medical Professional filling out this form on behalf of a family?

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HIdden Chapter Assignments

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Assign to Kathy*

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National*

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Assign to Shawna Roskoski*

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Michigan Chapter*

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Mid-Atlantic Chapter*

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Assign to Philly*

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Assign to Indiana*

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Assign to Indiana Chapter*

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Assign to Ann Fixari*

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Assign to Central Carolinas Chapter*

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Constituent Code

A Kid Again National Office
777-E Dearborn Park Lane Columbus, OH 43085

P: 614.797.9500
[email protected]

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