Participant - Rae’s Hope

Date of Birth (MM/DD/YY) *

Gender

Participant Legal Name *

First

Last

Name of School *

How are you related to the participant? *

Guardian Legal Name *

First

Last

Phone Number *

Email *

Home Address *

Emergency Contact *

First

Last

Phone Number *

I give permission for my child to participate fully in Rae’s Hope event, including lunch, snacks, and games. In case of an emergency, I understand that every effort will be made to contact the parent/guardian of the child(ren). In the event that the parent or guardian cannot be reached, the parent or guardian gives permission for the medical personnel selected by Raes Hope to secure proper and necessary treatment for your child. *

Please provide insurance name, policy number, policy holder name and phone number. *

I understand that pictures may be posted on Rae’s Hope website, newsletter, or social media platforms during Rae's Hope events to help us remember and share the outcomes. *