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Enroll to A Kid Again Form

Enrollment Application

"*" indicates required fields

Step 1 of 2 - Child's Information

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Thank you for your interest in becoming part of the A Kid Again family. 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.

Child's full name*

First Middle Last Suffix

Child's preferred name*

This is the name which you'd like A Kid Again to use to address your child.

Preferred

Date of Birth*

Child's Date of Birth

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]

Additional Diagnosis Information

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

Yes

Does your child require any of the following:*

Wheelchair/walking device

Non-Verbal

Feeding Tube

Trach

Vent

Home O2

Nurse/Health Aide

24 hour supervision

CPAP/BiPAP

None of the above

How many doctors see your child for treatment of their condition?*

Please enter a number from 0 to 30.

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Additional Autism Spectrum Disorder Questions

Does your child require constant supervision from an adult to prevent injury, harm to others, or elopement? Or supervision/prompting to complete daily tasks such as eating, toileting, dressing?*

Yes

Does your child have musculoskeletal or motor issues which impact their ability to walk or perform activities of daily living?*

Yes

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Additional Cerebral Palsy Questions

Does your child require a mobility device such as a wheelchair, walker, crutches, or canes on a daily basis?*

Yes

Does your child need significant assistance from an adult each day to perform activities of daily living (eating, toileting, dressing)?*

Yes

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Additional Trisomy 21/Down Syndrome Questions

Is your child’s Down Syndrome diagnosis coupled with any of the following: complex congenital heart disease, atlanto-axial instability, blood disease, immune system disorders, hypothyroidism, or feeding issues due to abnormal gastrointestinal organs?*

If you haven't listed these additional diagnoses as secondary diagnoses yet, please visit the diagnosis section of the application again to list additional diagnoses.

Yes

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.

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 Preferred Name*

First

Parent/Guardian Mobile Phone*

Parent/Guardian Email*

Parent/Guardian Birth Date*

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 Preferred Name*

First

Parent/Guardian Mobile Phone*

Parent/Guardian Birth Date*

Parent/Guardian Gender*

Male

Female

Non-Binary

Hidden

Sibling 7 Relationship

Hidden

Sibling 7 Reciprocal

Sibling Name*

First Last

Sibling Birth Date*

Sibling Gender*

Male

Female

Non-Binary

Other

Hidden

Sibling Information 8

Sibling Name*

First Last

Sibling Birth Date*

Sibling Gender*

Male

Female

Non-Binary

Other

Hidden

Sibling Information 9

Hidden

Sibling 9 Relationship

Hidden

Sibling 9 Reciprocal

Sibling Name*

First Last

Sibling Birth Date*

Sibling Gender*

Male

Female

Non-Binary

Other

Hidden

Sibling Information 10

Sibling Name*

First Last

Sibling Birth Date*

Sibling Gender*

Male

Female

Non-Binary

Other

Hidden

Sibling Information 11

Sibling Name*

First Last

Sibling Birth Date*

Sibling Gender*

Male

Female

Non-Binary

Other

Hidden

Sibling Information 12

Sibling Name*

First Last

Sibling Birth Date*

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

Other (specify below)

I'd prefer not to answer

Other (race of enrolled child):*

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

Facebook

Other Social Media

Franklin County Health Department

Friend

Haslinger Family Pediatric Palliative Care Center

Hospital/Social Worker/Child Life Specialist/Nurse

Internet

School

TV/Radio/News

Non-Profit Organization (Lis Below)

Other (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

Primary Language spoken in household*

Arabic

English

French

Mandarin

Nepali

Sign Language

Somali

Spanish

Other (specify below)

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*

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

Hidden

Assign to Kathy*

Hidden

National*

Hidden

Assign to Shawna Roskoski*

Hidden

Michigan Chapter*

Hidden

Mid-Atlantic Chapter*

Hidden

Assign to Philly*

Hidden

Assign to Indiana*

Hidden

Assign to Indiana Chapter*

Hidden

Assign to Jenny Provin*

Hidden

Assign to Central Carolinas Chapter*

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Constituent Code

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

P: 614.797.9500
[email protected]

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