Child Application Child's Name* First Last Child's Birthday* Child's gender* Male Female Present SchoolChild's T-Shirt SizeChild's Diagnosis*Does your child require wheelchair assistance?* Yes No Does your child participate in the Special Olympics?* Yes No Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Home Phone #*Mother's Cell #Father's Cell #I am the child's:* Mother Father Do you have your own transportation?* Yes No In miles - how far are you willing to travel to your child’s adopting team?*Mother's Name First Last Father's Name First Last Siblings Names / AgesSibling 1 First Last AgeSibling 2 First Last AgeGuardiansLegal Guardian 1 First Last Legal Guardian 2 First Last If child resides with one parent and the other parent is living, please attach a copy of the custody order or both parents must sign all documentsHow did you hear about Team Up For 1?Tell us about your childWhat are your child’s three favorite sports? *Please try to choose one for each season. (Ex: Soccer for Fall, Basketball for Winter, Lacrosse for Spring)What music does your child like?Favorite RestaurantsFavorite Characters from Books, Movies or TVFavorite CelebritiesFavorite HobbiesFavorite ColorsFavorite activities as a family (going to the zoo, etc.)Additional CommentsOther things you would like to tell us about your childLiability Permit:1. The undersigned has requested participation in Team Up For 1 programs. All participants agree to forever release and absolve Team Up For 1 Foundation for, from and against any and all liability, damages and claims of any kind, known and unknown which may be connected with a result from participation in Team Up For 1 participation programs. 2. Participants understand and agree that involvement in Team Up For 1 Foundation Programs may involve injury or harm to the Participants and agree that this risk is fully assumed by the Participants. This includes, but not limited to problems connected with transportation, lodging, food, all medical conditions, publicity to include photographs, accidental injury, death or harm to the Participants and that all risk is fully assumed by all Participants. Participants agree to carry full medical coverage or assume personal responsibility for failing to carry adequate medical insurance. The Participants hold Team Up For 1 Foundation harmless for any loss as the result of any claim, lawsuit or action arising out of or relating to the preparation, execution or fulfillment of the benefit conferred upon the Participants. 3. The undersigned both individually and on behalf of the child who is eligible to participate in Team Up For 1 Foundation Programs does release and absolve Team Up For 1 Foundation, their volunteers, employees, directors and agents and all other persons, businesses and corporations which may be liable from any and all actions, causes of action, claims and demands for, any damage for any incidents or occurrence which occur during the participation or consideration of participation in Team Up For 1 Foundation Programs. 4. The parent(s) or legal guardian(s) gives permission to Team Up For 1 Foundation to contact the physician and/or medical personnel familiar with the child's medical diagnosis. This will determine the child's eligibility in Team Up For 1 Foundation Programs. All physicians and/or medical personnel have permission to release my child's medical information to the Team Up For 1 Foundation. The parents or legal guardians have made true and full disclosure of the medical condition and all additional information to Team Up For 1Foundation. The parents or legal guardians understand that the Team Up For 1 Foundation may disclose their child's information to any third party involved in program participation. 5. It is further understood that this permit contains the entire agreement between the Participants and Team Up For 1 Foundation. All participants involved agree to the terms in this permit. This agreement expresses the understanding of all participants in Team Up For 1 Programs. By signing, you agree and acknowledge that you have fully read and understand this agreement. Publicity Permit:The undersigned agrees to the following: 1. It is understood and agreed that participation in Team Up For 1 Foundation Programs may result in publicity. By signing this permit you are allowing Team Up For 1Foundation to use the name, photos or video of all Participants, for publicity purposes. 2. Team Up For 1 Foundation is very aware of the desire for privacy and will respect any reasonable requests from program Participants. However, the media or general public may acquire information concerning the Participants and any event; thus publicity may result. Each Participant must understand that information regarding Team Up For 1 Programs may be publicized and the Participants release Team Up For 1 Foundation from all liability. Each of the Participants hereby releases Team Up For 1 Foundation from all damages, liability or claims resulting from, or arising from the use, distribution or disclosure of any photographs, films, newsletters, videotapes, websites, press releases or other information regarding Participants. 3. I agree that all Participants have read and understand this Publicity Permit for Team Up For 1 Foundation programs prior to signing it. The undersigned authorize and hereby bind themselves, their minor children, and all participants, their heirs, successors and estates to the conditions in this release. Each Participant agrees that this permit is accurate and expresses the understanding of each and every Participant. Each of the Participants agrees that no modification of this release has been made orally or in writing and this release accurately and fully expresses the understanding of all Participants 4. By submitting this form, you agree and acknowledge that you have read and fully understand this agreement. All Participants involved agree to all terms in this permit. The agreement expresses the understanding of all Participants in Team Up For 1 Foundation Programs. 5. It is further understood that this release contains the entire agreement between the Participants and Team Up For 1 Foundation concerning publicity. All Participants involved agree to the terms in this release. This agreement expresses the understanding of all participants in Team Up For 1 Programs. By signing, you agree and acknowledge that you have fully read and understand this agreement. By signing this permit, you are allowing Team Up For 1 Foundation to use the name, photos or video of all Participants for publicity purposes. Type Name* First Last Date This iframe contains the logic required to handle AJAX powered Gravity Forms.