CHAT RSVP - Tom Coughlin Jay Fund

C.H.A.T. Event

C.H.A.T. Event: Find your pot of gold!

Thursday, October 17

6:30-8:30 pm

Culhane's Irish Pub - 9720 Deer Lake Court Blvd, Jacksonville, FL 32246

Your RSVP won’t be complete until the Nemours waiver form is filled out and returned. This event is for Oncology Patients Only - Ages 13 and older.

If your child is on active treatment or otherwise immunocompromised, please consult with your doctor about any safety concerns before attending this event.

If you have any questions, please contact [email protected].

Parent/Guardian information:
Name*
Prefix First Last
Email*
Cell Phone*
Patient Information:
Patient's Name:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Patient's cancer diagnosis:*
Patient's Date of Diagnosis:*
MM slash DD slash YYYY
Hospital/Treatment Facility Name:*
Photography and Video Recording Consent*
I grant The Tom Coughlin Jay Fund Foundation full and complete permission to photograph, record, videotape, or otherwise record the voice, likeness and/or appearance of myself and the participant(s) named above, and to use, reproduce, display, distribute, modify, transmit, transfer, assign and license all such recordings and photographs for any purpose in any media and by all means, now known or hereafter devised, throughout the universe, in perpetuity.
COVID-19 Consent*
I understand that by agreeing to be at the Event and agreeing to participate in the Event there is a possibility that the Participant could be exposed to the coronavirus (COVID-19). I attest to the fact that the Participant has not tested positive for COVID-19 and has not knowingly been within close proximity to anyone who tested positive for COVID-19. I further attest to the fact that the Participant has not had any of the known symptoms of COVID-19 (e.g., fever, cough, shortness of breath or difficulty breathing, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell). I agree to immediately notify Tom Coughlin Jay Fund if I acquire any knowledge that the Participant has been exposed to COVID-19 and/or if the Participant has symptoms of COVID-19 and, in either such case, I agree that the Participant will immediately cease attendance at the Event. I acknowledge that Tom Coughlin Jay Fund is taking reasonable measures to prevent the transmission of COVID-19 consistent with applicable public health guidelines. I also acknowledge and recognize that it is impossible to ensure that the organization and events are 100% free of COVID-19 and that being at the Event, as well as participating in the Event, contain inherent risks that cannot be eliminated regardless of the care taken to avoid the spread of COVID-19. I acknowledge, understand, and appreciate these and other risks are inherent in participating in the Event. I hereby release, waive, discharge, covenant not to sue, and agree to hold harmless for all purposes the Tom Coughlin Jay Fund and its Directors, employees, volunteers, donors, related parties, or other organizations (“Releasees”) associated with any program or activity from any and all liabilities, claims, demands, or injuries, including death, that may be sustained by me and/or the Participant because of Participant’s attendance, and/or participation in activities at the Event.

C.H.A.T. Event

Parent/Guardian information:

Patient Information: