Get Help - Tom Coughlin Jay Fund

Remembrance Weekend 2022

Remembrance Weekend Application Form:
We invite all to complete the application below. Although we may not be able to accommodate all who apply, our hope is to have families at various stages of their grief journey. Please complete the application form below by Friday, May 20, 2022. You will be notified of the status of your family’s application by Friday, May 27, 2022. If you have any questions, please contact [email protected].
Name of child to be remembered:*
First Middle Last
Date of Birth:*
MM slash DD slash YYYY
Date of Death:*
MM slash DD slash YYYY
Adult #1's Name:
First Last
Adult #1's Cell Phone*
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Adult #2's Name:
First Last
Adult #2's Cell Phone*
Additional attendees:
The weekend is for immediate family members, which includes only parents/guardians and siblings. It does not include adult siblings that have their own family, aunts, uncles, or cousins.
Sibling (1) Name:
First Last
Sibling (1) Date of Birth:
MM slash DD slash YYYY
Sibling (2) Name:
First Last
Sibling (2) Date of Birth:
MM slash DD slash YYYY
Sibling (3) Name:
First Last
Sibling (3) Date of Birth:
MM slash DD slash YYYY
Sibling (4) Name:
First Last
Sibling (4) Date of Birth:
MM slash DD slash YYYY
Sibling (5) Name:
First Last
Sibling (5) Date of Birth:
MM slash DD slash YYYY
Additional Siblings' Names, and Dates of Birth
Total number of Immediate family members attending (Parents/Guardians and siblings):*
Check in is from 4:00-6:30pm. If attendance is confirmed, do you plan to arrive AFTER 6:30pm?
My completion of the above application indicates that I intend to participate in all the activities throughout the weekend.
Any special dietary needs or other special accommodations required?
If attendance is confirmed, what specific topics would you like to hear presented in the adult session?
COVID-19 Acknowledgement*
I understand.
I understand that by agreeing to be at the Experience and agreeing to participate that there is a possibility that the Participant(s) could be exposed to the coronavirus (COVID-19). I attest to the fact that the Participant(s) 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(s) 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(s) has been exposed to COVID-19 and/or if the Participant(s) has symptoms of COVID-19 and, in either such case, I agree that the Participant(s) will immediately cease attendance at the Experience. 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 experiences are 100% free of COVID-19 and that being at the Experience, as well as participating in the Experience, 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 Experience. 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 Experience.
Jay Fund Photo 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.

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Remembrance Weekend 2022

Remembrance Weekend Application Form:

Additional attendees: