A Kid Again
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Enroll Give

A Kid Again Enrollment Form

Step 1 of 3

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  • Chapter Assignment

  • Enrolled Child Information

  • Date Format: MM slash DD slash YYYY
    A Kid Again Serves Children up to the Age of 20
  • Additional Diagnosis

  • Additional Diagnosis 2

  • Additional Diagnosis 3

  • Section Break

  • Hospital Information

  • 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.
  • Parent/Guardian Information

  • Second Parent/Guardian

  • Contact Information

    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.
  • Date Format: MM slash DD slash YYYY
  • Sibling 2

  • Date Format: MM slash DD slash YYYY
  • Sibling 3

  • Date Format: MM slash DD slash YYYY
  • Sibling 4

  • Date Format: MM slash DD slash YYYY
  • Sibling 5

  • Date Format: MM slash DD slash YYYY
  • Sibling 6

  • Date Format: MM slash DD slash YYYY
  • Sibling 7

  • Date Format: MM slash DD slash YYYY
  • Sibling 8

  • Date Format: MM slash DD slash YYYY
  • Sibling 9

  • Date Format: MM slash DD slash YYYY
  • Sibling 10

  • Date Format: MM slash DD slash YYYY
  • Foster Parents

  • 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.
  • 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.
  • 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.
  • Date Format: MM slash DD slash YYYY
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  • 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.
  • 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.
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National Office

777-G Dearborn Park Lane Columbus, OH 43085
P: 614.797.9500
F: 614.797.9600
customerservice@akidagain.org
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