A Kid Again Enrollment Form

Select Your State of Residence*
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*
Chapter Assignment
Assign to Kathy*
National*
Assign to Amy Vining*
Michigan Chapter*
Assign to Philly*
Mid-Atlantic Chapter*
Assign to Indiana*
Assign to Indiana Chapter*
Assign to Jenny Provin*
Assign to Central Carolinas Chapter*
Enrolled Child Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Gender*
DOB*
Date Format: MM slash DD slash YYYY

A Kid Again Serves Children up to the Age of 20
Select Primary Diagnosis Category of Child (qualified life-threatening)*
Please Specify name of Child's Primary Diagnosis (as listed on medical records)*
Please only list one diagnosis per text field.
Do you have any additional Diagnoses?*
- Yes
- No
Additional Diagnosis
Additional Diagnosis
Please Specify name of Child's Diagnosis (as listed on medical records)*
Please only list one diagnosis per text field.
Do you have any additional Diagnoses?*
- Yes
- No
Additional Diagnosis 2
Additional Diagnosis*
Please Specify name of Child's Diagnosis (as listed on medical records)*
Please only list one diagnosis per text field.
Do you have any additional Diagnoses?*
- Yes
- No
Additional Diagnosis 3
Additional Diagnosis*
Please Specify name of Child's Diagnosis (as listed on medical records)*
Please only list one diagnosis per text field.
Section Break
Does your child require wheel chair access?*
- Yes
- No
Does your family have a nurse/home healthcare aide?*
- Yes
- No
My child has (check all that apply):
- Select All
- Non-verbal
- Sensory Disorder
- Feeding Tube
- Tracheostomy
- Ventilator
- Home Oxygen
- Home Bipap/Cpap
With how many doctors or specialists does your child routinely have appointments (Besides Pediatrician/Primary Care Physician, Eye Doctor, Dentist)?*
Is your child seen by a complex care unit, palliative care, or hospice?*
- Yes
- No
Hospital Information
Hospital Providing Care*
Other Hospital or Medical Center*
Social Worker/Medical Provider
By completing the below information, you are providing permission for A Kid Again to reach out to your social worker to request medical authorization. If we are unable to complete this request an A Kid Again representative will reach out for additional support.
Name of Social Worker/Medical Provider
First Last
Email of Social Worker/Medical Provider
Parent/Guardian Information
Full Name of Mother/Father/Guardian #1*
First Last
Relationship
Reciprocal Relationship
Does the Guardian listed above live at the same address as the child?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Do you have an additional Parent/Guardian to enter?*
- Yes
- No
Second Parent/Guardian
Full Name of Father/Mother/Guardian #2*
First Last
Does the Guardian listed above live at the same address as the child?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Contact Information
Primary Phone Type*
Primary Phone Number*
Alternate Phone Type
Alternate Phone Number
Primary Email*
Secondary Email
Family Website, Blog, Facebook Page, or Caring Page
Does your Child Have any Siblings?*
- Yes
- No
Please add each sibling that lives in the household of the enrolled child.
Sibling Information
Please add information for each sibling that lives in the household of the enrolled child.
Name*
First Last
Gender*
- Male
- Female
DOB:*
Date Format: MM slash DD slash YYYY
Does your child have any additional siblings?*
- Yes
- No
Sibling 2
Name*
First Last
Gender*
- Male
- Female
DOB:*
Date Format: MM slash DD slash YYYY
Does your child have any additional siblings?*
- Yes
- No
Sibling 3
Name*
First Last
Gender*
- Male
- Female
DOB:*
Date Format: MM slash DD slash YYYY
Does your child have any additional siblings?*
- Yes
- No
Sibling 4
Name*
First Last
Gender*
- Male
- Female
DOB:*
Date Format: MM slash DD slash YYYY
Does your child have any additional siblings?*
- Yes
- No
Sibling 5
Name*
First Last
Gender*
- Male
- Female
DOB:*
Date Format: MM slash DD slash YYYY
Does your child have any additional siblings?*
- Yes
- No
Sibling 6
Name*
First Last
Gender*
- Male
- Female
DOB:*
Date Format: MM slash DD slash YYYY
Does your child have any additional siblings?*
- Yes
- No
Sibling 7
Name*
First Last
Gender*
- Male
- Female
DOB:*
Date Format: MM slash DD slash YYYY
Does your child have any additional siblings?*
- Yes
- No
Sibling 8
Name*
First Last
Gender*
- Male
- Female
DOB:*
Date Format: MM slash DD slash YYYY
Does your child have any additional siblings?*
- Yes
- No
Sibling 9
Name*
First Last
Gender*
- Male
- Female
DOB:*
Date Format: MM slash DD slash YYYY
Does your child have any additional siblings?*
- Yes
- No
Sibling 10
Name*
First Last
Gender*
- Male
- Female
DOB:*
Date Format: MM slash DD slash YYYY
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.
Please upload legal documentation.*
Accepted file types: jpg, png, pdf.
Acceptable file formats are jpg, png, or pdf

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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 Twitter. 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.
Accordingly (please select one of the following)*
- Yes! By my signature below I/we authorize A Kid Again to photograph, film, or electronically record me/us and distribute such materials as A Kid Again chooses. By my signature below, I also authorize A Kid Again to post updates or photographs of me/my child on social media which may include our names and/or my child’s medical condition.
- No. I do not authorize A Kid Again to photograph, film, or electronically record me/us and distribute such materials. I do not authorize A Kid Again to post updates or photographs of me/my child on social media. I understand that most A Kid Again events take place in a group setting. Therefore, I understand that it is my/our responsibility to excuse ourselves and my child 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/our and my/our child’s non-participation. In the event I/we do not excuse ourselves or promptly notify A Kid Again of our non-participation, I hereby waive my/our and my child’s non-participation in that instance.
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 hereby state that I have read the forgoing release and have executed it freely, voluntarily and without remuneration. I give my permission for myself and/or children to participate in A Kid Again outings as outlined herein.
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 Signature*
Parent/Guardian Name*
First Last
Date*
Date Format: MM slash DD slash YYYY

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A Kid Again Enrollment Form

Step 1 of 3

Chapter Assignment

Enrolled Child Information

Additional Diagnosis

Additional Diagnosis 2

Additional Diagnosis 3

Section Break

Hospital Information

Social Worker/Medical Provider

Parent/Guardian Information

Second Parent/Guardian

Contact Information

Sibling Information

Sibling 2

Sibling 3

Sibling 4

Sibling 5

Sibling 6

Sibling 7

Sibling 8

Sibling 9

Sibling 10

Foster Parents

Liability Waiver

Additional Liability Release and Authorization

Research Studies

Personal Information

Employer Information