2024-School Bash Registration Form

Name

Spouse

Phone

Address

This address will receive a confirmation email

If you do not receive an Email check your Spam file.

Name of Sick Child/Person

Age

Gender

Date of Birth

Month & Year Diagnosed

Type of Cancer

Current Treatments. Please update us as to current treatments. If none-say none. Sees the dr. how many times a week or month. This will go into your chart. Thank you

Child 2-Name

Age

Gender

Date of Birth Child 2

Child 3-Name

Age

Gender

Date Of Birth Child 3

Child 4-Name

Age

Gender

Date Of Birth Child 4

Child 5-Name

Age

Gender

Date of Birth Child 5

Child 6 Name

Age

Gender

Date of Birth Child 6

Child 7 name

Age

Gender

Date of Birth-Child 7

Child 8 Name

Age

Gender

Date of Birth-Child 8

Any other Minor Children. List Name-Age-Date of Birth

Emergency Contact Person

Cell Phone

Date

I /We do hereby release my/our story and my/our picture(s) to ADONAI, Inc. to be used to promote the success stories of ADONAI, Inc., its services and the successful support it provides to families in our community. Pictures & stories may be used in posters, newsletters, internet website, etc. I/We also acknowledge there shall be no financial or otherwise compensation paid, implied, guaranteed or suggested to you and/or your family, business or employer.

Description

Friday August 2, 2024

Please fill out this form and click submit.

2024-School Bash Registration Form

Description

Please Fix the Following