Tom Coughlin Jay Fund Holiday Movie ExperienceIf you have any questions, please contact [email protected] Parent/Guardian information:Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Email* Phone*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Spouse/Partner Attending's Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last 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:* Sibling Information:This event is for immediate family only. 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 BirthTotal number of Immediate family members attending (Patient, Parents/Guardians, and siblings):*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. Δ
